HomeMy WebLinkAboutWIANNO CLUB - SNACK BAR - FOOD 371 P(A Lkf off _
to IK1 Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
BAR.NSTABLL F.P.(Thomas)Lee
t MASS Daniel Luczkow,M.D. Alt.
+679 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 108 Issue Date: 01/01/2022
DBA: WIANNO GOLF CLUB SNACK BAR
OWNER: WIANNO CLUB INC
Location of Establishment: 379 PARKER ROAD OSTERVILLE, MA 02655
Type of Business Permit: FOOD SERVICE
Annual: Seasonal: YES
Incloor5eating: 50 OutcloorSeating: 40 Total Seating: 90
FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B- FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: CQ�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
Only.For Office Use Initials
.� Town of Barnstable
Date Paid Amt pd$
BARNWABM : Inspectional Services �b
16 9. �� Check
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
2 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 101 NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: W I W I h
ADDRESS OF FOOD ESTABLISHMENT: 3qq ! "/ K-tr '�A/t''C 62-V,
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 7v 13 c 2-0 OJiawl Ile ` 2-46�0(
E-MAIL ADDRESS: �- w 1 W I�'1 D ril(�(� '&WYL
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 6—Lc
TOTAL NUMBER OF BATHROOMS: 4
WELL WATER:YES NO__x ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: X DATES OF OPERATION: ///ZZTO /0/ /1 /
NUMBER OF SEATS: INSIDE: 50 OUTSIDE: 40 TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING.AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? eS
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? n
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES...(MONTHLY LAB ANALYSIS REQUIRED)
.CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:Wpplication FormsTOODAPP 2020.doe
4 OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: YES/ O D.O.B OWNER PHONE#
e
ADDRESS �V O.J�C,I�I-V I to Ave h
CORPORATE OWNER:
CORPORATE ADDRESS:PERSON IN CHARGE OF DAILY OPERATIONS: / �'M`O—e, KEG bs
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Ex iration Date Allergen Awareness Eg iration Date
2-OL
qi 14 i zZ 1.1'Yl �C�1�,Q,� u�1�AQ� i
2.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTowri by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/api)lications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q\Application FonusTOODAPP REV3-2019.doc
* BOARD OF HEALTH
Town of Barnstable John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
= n�rt� raare Paul J.Canniff,D.M.D.
�$ n °' 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 108 Issue Date: 01/01/2021
DBA: WIANNO GOLF CLUB SNACK BAR
OWNER: WIANNO CLUB INC
Location of Establishment: 379 PARKER ROAD OSTERVILLE, MA 02655
Type of Business Permit: FOOD SERVICE
Annual: Seasonal: YES
IndoorSeating: 50 OutdoorSeating: 40 Total Seating: 90
FEES
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - - -z - - -- ---
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
f FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
h
oF�NE rq� Only: Initials:
do Town of Barnstable h
Date Paid Amt pd$. U
• 36-
RMW9rABM Inspectional Services
9� 1639. ,�g toy—
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL Y
NAME OF FOOD ESTABLISHMENT: WI W►nb e t O 1141b 5 n4tic
ADDRESS OF FOOD ESTABLISHMENT: A ' r` eJf-ekv at'e ft-u+ 6
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 'P0'96K 7, 1 D cS i l e 02
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ay,*8 - l q 91 Ix-
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NOX ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: _�DATES OF OPERATION:' (/1MTO I U/I�lz
NUMBER OF SEATS: INSIDE: �9? OUTSIDE: `40 TOTAL: 90
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? / ) D
r
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\ApplicationFon-ns\FOODAPP202O.doc
OWNER INFORMATION: '(,FULL NAME OF APPLICANT V"! / Jr)C
SOLE OWNER: YES/0 D.O.B OWNER PHONE#
ADDRESS Ibi S wv i tto ALL
���Gf'Y! 1�C�1 l►�1T �Z i
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS: Kq,6 5
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
�1.1Wil (Q— / �Z / ZZ l.m1C 4/ ?J / ZZ
2.- n Z3 / 7,3
SIGNATURE O ANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to ovenina!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.ast).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application ForinsTOODAPP REV3-2019.doc
� ss/nk ohfiie.
Town of Barnstable BOARD OF HEALTH
John T.Norman
* Board of Health Donald A.Gaudagnoli,M.D.
•�BAMI ABM Paul J.Canniff,D.M.D.
MAM 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
.a 3q
°ram° Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 108 Issue Date: 01/01/2020
DBA: WIANNO GOLF CLUB SNACK BAR
OWNER: WIANNO CLUB INC
Location of Establishment: 379 PARKER ROAD OSTERVILLE, MA 02655
Type of Business Permit: FOOD SERVICE
Annual: Seasonal: YES
IndoorSeating: 50 OutdoorSeating: 40 Total Seating: 90
FEES
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: an
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
rO"ti Town of Barnstable For Office Use Only: Initials:
• o„
• anrwsrna�.e.
Inspectional Services Date Paid 3 � Amt Pd$ 30o-
9� Public Health Division Check# o '145 og P 10
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE/J 1/ l LU NEW OWNERSHIP RENEWAL_X
y%aNAME OF FOOD ESTABLISHMENT: h(� �l `��l (i!�iG� � C�
ADDRESS OF FOOD ESTABLISHMENT:
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): pU 24- (.D ` U��
E-MAIL ADDRESS: \�I- ivlbui ny Cl u6 o CUY/L
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 7(i?� -
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES_NO X ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: ') 1J3/20TO 10113 / 2-0
NUMBER OF SEATS: INSIDE: 5'D OUTSIDE: L�b TOTAL: GI(7
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV AND LICENSING AND MEET OUTSIDE DINING
REOU IREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? I
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE &NEW FOOD ONLY***
R_EQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
QAApplication FormsTOODAPP 2020.doc
0
OWNER INFORMATION: J �t
FULL NAME OF APPLICANT r�,( Lh n b N lick --7741
SOLE OWNER: YES NO D.O.B OWNER PHONE
ADDRESS_ lb-1 - &LVIIW AVej1i -t,) 06i&y (e, m/f----ort,.AsS-
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS: 'to"
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1. mlcl�x�( �11 It ells- , rZ , �Z 1A 3 , zz
2. Pi n 4,er Lie l 1a ,2-3 , 73
SIG3 ATUR.E O AP ANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
.with sample results submitted to the Health_ Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at httP:/hvww.townofbarnstable.us/healthdivision/applications asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q\Application FormsWOODAPP REV3-2019.doc
,t
ii t p@J Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
ST
John T. Norman
A F.P. Thomas Lee Alternate
7� asg 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
.Permit No: 108 Issue Date: 03/26/2019
DBA: WIANNO GOLF CLUB SNACK BAR
OWNER: WIANNO CLUB INC
Location of Establishment: 379 PARKER ROAD OSTERVILLE MA 02655
Type of Business Permit: FOOD SERVICE
Annual: Seasonal: YES
IndoorSeating: 50 OutdoorSeating: 40 Total Seating: 90
FEES
FOOD SERVIC E ESTABLISHMENT: $300.00 YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: --— - --------
MOBILE-FOOD:
MOBILE-ICE CREAM: C�A
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�I
, F
,Of IVfE Tod • Initials:
Town of Barnstable _ ,
Dates aid q Amy$
BARNSTABLE, Inspectional Services
y MASS.
� i
�A i639' Ch�cli_ '
rEDMP�A Public Health Division
Thomas McKean.,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT E
DA'1E NEW OWNERSHIP RENEWAL _
k
NAME OF FOOD ESTABLISHMENT: Immob
ADDRESS OF FOOD ESTABLISHMENT: 9 73 yaA5
MAILING ADDRESS (IF DIFFERENT FROM ABOVE): p� 0 0� ��y � I 1 l v"�
E-MAIL ADDRESS: � ('i� et
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES_NO (ANNUAL WATER ANALYSIS REQUIRED)
ANIVUAL: SEASONAL: X DATES OF OPERATION: 5l,6-/l TO /0 114 /M
Opev-\ C A+-2: F
NUMBER OF SEATS: INSIDE: OUTSIDE: 40 TOTAL:
r.
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER*** F;
r
OUTSIDE DINING MUST 13E APPROVED BY THE HEALTH DIV,AND LICENSING AND MEET OUTSIDE DINING
%
REQUIREMENTS.
C
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
r
f
FOOD SERVICE
r
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) I,
BED &BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD j
_FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING .- (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE & NEW FOOD ONLY*** 'F
R
REQUIRED TO CALL HEALTH DIV.FOR INSPI CTION PRIOR TO PERMIT BEING ISSUED
Q`,Application Forms\FOODAPPRGV2018.doc
P.
Y
E
a. i
t
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: YES O—) D.O.B /� OWNER PHONE# �
ADDRESS I� 1 I.�� I l l► t d�—W�� t,
CORPORATE OWNER: FEDERAL ID NO. :
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES" The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Aller en Awareness Expiration Date F
Ia-- p Z ZZ, J?i`�/o .-'-��3 � Z-
f
SIGNATURE ANT DATE
r
ti
""FOOD POLICY INFORMATION"*
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div,
i
prior-to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
i
CAPERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
even. You must complete a catering notice found at http://www r.townofbanstable,us/healkhdivision/applications.asp. r
i
( 4
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS; All tobacco establishments must complete an Application for Tobacco Sales Permit and
Emp'.oyee Signature Form.
NOTICE: Permits nun annually ftom January Ist to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RFTURN
THE COMPLETED APPUCATION(S)AND REQUIRED FEES BY DEC I st.
Q:\Appflcatioii FornisTOODAPPREV2018.doc
f
F
t r�
\�
Bellaire, Dianna axu16 CL4,6 I lue,
From: Miorandi, Donna
Sent: Tuesday, October 13, 2020 4:15 PM
To: Bellaire, Dianna
Cc: Michael Pillarella (chef michael@wiannoclub.com)
Subject: Wianno Club on Parker Road, Osterville
Hi Dianna: Just one thing for the future (probably spring) . They would like to have a grill outside with some
refrigeration just off the deck of the building. They plan on it being temporary and would have a tent and realize they
would need Fire Dept. approval. Initially they said no hand sink but I think our office is going to require it as it is
probably more than 20 ft.to the sink for the inside kitchen. They also weren't planning on any particular flooring just
stone but I said they would probably need something that is washable, scrubbable. Anyhow they are working on plans
and pricing but just had me on site to see and possibly answer some questions. It was Chef Michael Pillarella and his
assistant Eric that I met with. Don't know if you want to put this in the file for future planning and discussion. But
when it does come up I didn't want it to be the first someone heard of it. Anyhow I shall copy Chef Michael on this
too. Take care and see you soon in office when I return my phone,tablets, etc.
Lbonna Z Miorancri, A.- .
Town of Barnstable
Health Inspector
Public Health Division
200 Main Street, Hyannis, MA 02601
The information contained in this electronic transmission ("e-mail"), including any attachment(the "Information"),
may be confidential or otherwise exempt from disclosure. It is for the addressee only.This information may be
privileged and confidential work-product or a privileged and confidential communication.The Information may also
be deliberative and pre-decisional in nature.As such, it is for internal use only.The Information may not be disclosed
without the prior written consent of the Director of Public Health and/or the Town Attorney's Office of the Town of
Barnstable. If you have received this e-mail by mistake, please notify the sender and delete it from your system.
Please do not copy or forward it.Thank you for your cooperation.
1
Of 111E rpk, TOWN OF BARNSTABLE HEALTH.INSPECTORs Establishment Name: Date: Page: / of
c OFFICE HOURS
PUBLIC HEALTH DIVISION a:oo-s:soA.M.
BARNSfABLE. • 200 MAIN STREET s:so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. o� HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item. PLEASE PRINT CLEARLY
508-862-4644
'EDN10� FOOD ESTABLISHMENT INSPECTION REPORT -f-
Name ICt4U4,j / �Q,� Date.� Type of -Type of Inspection
6� L ` tr Routine
Address �/L.� P�- Risk Food Service Re-inspection /D ,
J Level RM-aff Previous Inspection
Telephone Residential Kitchen Date-
Mobile re-operation r L✓
Owner HACCP Y/N Temporary ss >1
Caterer General Complaint r
Person in Charge(PIC) l 1 Time Bed&Breakfast HACCP Z) �.V�
In: n_ ,, Other /
Inspector n _Soh Out: l�V
Each violation checked re uires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 690.009(E) ❑ - L4O /
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ ( T 7 '
Action as determined by the Board of Health. Allergen Awareness 590.009(G)
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 1
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ~L f l✓(� r� �CQ
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 10ic __E a t, / C] f
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating -�
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items Total Number of Critical ViolationsW
�
❑ El
(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo Emergency Closure
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ 9 Y ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations
if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 n - ritical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
Inspector's 'ign ure PrL
�/�`� G✓�30.Other DATE OF RE-INSPECTION:31.Dumpsterscreened from public view /l
Permit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N C's.Sig rer Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N i
Dumpster Screen? Y N
�,,...+�._. � _-.-..�.,'.y._.�,....-...-,-...�.-`�.,_.�..... __-•.-ter-'...r.-..`.�-.-.ram-,...�.. � _. r- _ _ -..r---� -�-..�"�...-.v �. __ _ ._ �-._-� _ �.-..-._.. ��- -��-��.-...�_..- - -m_.�-. --�.�.---. -`-. ._ _.�-�- ___. - .� __..4_ _.-. �. - --�_ _
Violations related to Foodborne Illness Violation Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* S Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* g
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and AdulteReserrated
or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures Raw Seed Sprouts Not Served*
* 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg dive 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) _ Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* i 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 70 Proper,Adequate Handwashing g' p �'
Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* _ 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.1](A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g.' Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
13 Handwashing Facilities
3-202.18 Shellstock Identification* { 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients'
Supplied with Soap and hand Drying Devices `
1
27. ' Physical Facility % FC-6 - .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials % FC,!7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria* y 6
c'
8-103.12 Conformance with Approved Procedures* S:590Forrnback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. I *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
f
`oF11HE Tokti TOWN OF BARNSTABLE ,HEALTH INSPECTORS Establishment Name: �Y(UC Date: 7 Page: of
o OFFICE HOURS 4 1.
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
'� ayy �•� HYANNIS, MA 02601 M- -FRI.
s No Reference R--,Red Item PLEASE PRINT CLEARLY.
FOOD ESTABLISHMENT INSPECTION REPORT oa8 s2-4644
Name Date Type o ly299*1rispection
Routine.
Address � j j �- Risk Food Se Re-inspection
��. 6 Level Retail Previous Inspection
Telephone Residential Kitchen Date: 3 �
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness a` f-�
Caterer General Complaint
Person in.Charge(PIC) 111� Time Bed&Breakfast HACCP
In: �'Z �►� Other
Inspector -6v Out: -2T D ` dam
Each violation checked requi es an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009 G
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS --
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) V
1714.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating -
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control C XJG(�,
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) u.
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22•.Posting of Consumer Advisories v q
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations lC
Critical(C)violations marked must be corrected immediately. (blue 8r red items) Corrective Action Required: ❑ No ❑ Yes
Non-criticaF(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating
Y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items o Embar
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 ardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations re
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7(590.008 9 =
29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations C.
30.Other DATE OF RE-INSPECTION: Inspector's Sign ure Prin1E/ q
31.Dum Sler Screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si re Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness- Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8q3-302.11(A)(2)
ross-contamination 14 Food or.ColorAdditives. Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* aw Animal Foods Separated from 3-202:12- Additives* 3-501.15 Cooling Methods for PHFs
ooked and RTE Foods.* * 1.9 PHF Hot and Cole[Holding
2-103.11 Person-in-Charge Duties - 3-302.14 Protectiomf`rom Unapproved Additives
ontamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH aw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
* 3-501.16(A) Hot PHFs Maintained At or Above 140°F590.003(C) ' Responsibility.of the Person-.in-Charge to ther i _ 7-102.11 Common Name-WorkingContainers*
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Stma e
Applicants* 3-302.11(A) Food Protection* I = P g 20 Time as a Public Health Control
I • 7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils*-
tensils * ( ) 9
590.003(G) Reporting by Person in Charge* _ _ 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions g � )
Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources y Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501:111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13. ,-Shell Eggs* -._ Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-lO1.I1_... Drinking Water from an Approved System* __ * gg Not Otherwise Processed to Eliminate
Equipment
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sg true trrrzooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 - ' Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
- * - Ratites-165°F 15 sec* in mobile food,tempor and residential
Sources 70 Proper,Adequate Handwashing g'
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3=202.18' Shellstock Identification Present* 2-301.12 _ Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
2-301.14 When to Wash* * Other 590.009 violations relating to good retail
_ - 590.004(C)_-. Wild Mushrooms* _. _ _ _ - 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec practices should be debited under#29-Special
3-201.17 Game Animals* 11 Good Hygienic Practices 17 _ Reheating for Hot Holding Requirements.
$ " ' - Receiving/Condition 2 401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140'F* Blue Items 23-30)
3-202.15 Package Integrity O Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
590.004 E) Preventing Contamination from Employees* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock ( S18- Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70*F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients`
Supplied with Soap and hand Drying Devices
27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability
28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria* -
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
`Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
�F.ME rok, TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: ( of
OFFICE HOURS
HEAL
TH ILTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
9$A MASS.s• MON HYANNIS, MA 02601 08-8 -464FRI No Reference R-Red Item PLEASE PRINT CLEARLY
rFo MPS � 508-862-0644
FOOD ESTABLISHMENT INSPECTION REPORT
Name " D Dat �1 L Type of Ins c ' n
Routin I Q
Address Risk Fo e-inspection
Level Retail Previous Inspection
Telephone Residential Kitchen D
Mobile re-operati r, l
Owner HACCP Y/N Temporary Su ec IlnessC age
Caterer General Complaint
Person in Charge(PIC) 1' �` Time Bed&Breakfast Other
HACCP
In:
Inspector rab Out: it.I� a��
Each violation checked re Tres an explanation on the narrative page(s)and a citation of specific provision(s)violated. / t
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ t Yt
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ D
Action as determined by the Board of Health. Allergen Awareness 590.009(G)
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands S�
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) J �Y
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating Q
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) r
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations rmlor(
I
Critical(C)violations marked must be corrected immediately. (blue&red items) l \ Corrective Action Required: ❑ No El Yes
Non-critical(N)violations must be corrected immediately or Overall Rating ._--
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4non-critical violations g
) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to a non-critical
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address tical violations. If 1 critical refrigeration.
violation,4 to 8non-critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
Inspector's Si t re Print-
DATE Other PATE OF RE-INSPECTION:
m no-pster scrccned from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F
EMPLOYEE HEALTH 3-302.11 A 2 Raw Animal Foods Separated from Each * 590.004(F)
( )O P 7-101.11 Identifying Information-Original Containers *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment P Storage*
3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Stora e
Applicants* 3-302.11(A) Food Protection* 1 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
, P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* * 8g Not Otherwise Processed to Eliminate
Equipment
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 8 590.009(A).-(D) Violations of Section 590.009(A)-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources g• P arY
1p Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requiremenpractices ts should be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.1I(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* (Blue Items 2330)
3-201.11 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome
* 12 Prevention of Contamination from Hands 3 403.11 Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated �) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Ln Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 1 g Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70'F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance
Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. physical Facility FC-6 .007
7 Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability
28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
vabc�oF. roy TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: ate age: of
P� �o Oro)
OFFICE HOURS
PUBLIC HEALTH DIVISION - � e:oo-s:3o A.M.
BARNSTABLE. • �)/ 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
AS �`/�J�-J666^^^ HYANNIS,MA 02601 - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
508-8624644
rFO MPS FOOD ESTABLISHMENT INSPE TI N REPORT -
Name Date De of Tvoe of Inspection �
Routine
Address Risk F d Serf Re-inspection
Level Previous Inspection NU A
Telephone Residential Kitchen
Mobile Ficl
Owner HACCP Y/N Temporary 0
Caterer General Complaint
If f
Person in Charge(PIC Time Bed&Breakfast HACCP 49
Other
Inspector lz�- A V)N4 aml TA V)J7 1at:
Each violation checked requires'an explanation on the narrat a page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G)
5>'1
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities c
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives -
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) f
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating y
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 'a)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ® Yes
Non-critical(N)violations must be corrected immediatelyyor
within 90 days as determined b the Board of Health. Overall Rating Voluntary Compliance
Y y ❑ ry p _ ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ® Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:.
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils.. (FC-4)(590.005 B=One critical violation and less than 4npn-critical violations 9
) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 n io!A ns violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8npn-critical viol tions-
29.Special Requirements (590.009) within 10 days of receipt of this order. ,
30.Other DATE OF RE-INSPECTION: In a or's ignature
31.Dumpster screened from public view 0
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PI 's Sign PRnt:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y. N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45°F Within 4 Hours*
* * 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
7-102.11 Common Name-Working Containers*
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
590.003(C) Responsibility of the Pelson-in-Charge to Other* *
3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130`F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* p g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.00411 Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
( ) Variance
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions*590.003(E) Removal of Exclusions and Restricti 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
ons Disposition of Adulterated or Contaminated
1 Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155`F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cave 1112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
f
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( )- ide tial er-
* Ratites-165`F IS sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g'
Game and Wild Mushrooms Approved B 3 401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under
Regulatory Authority y 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140'F* (Blue Items non-critical
23-30)
3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the Foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'17 to 70°F
Conveniently Located and Accessible Within 2 Hours and From 70`F to 41'F/45°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained*
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41'F/45`F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301,11 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 1 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
)1A Af
THE rok� TOWN OF BARNSTABLE, HEALTH INSPECTOR'S
N oCTSR'S Establishment Name: G-af _ Dater _ Page: of
PUBLIC HEALTH DIVISION �i� ICE0-9:30A.M.
BARNSTABLE. • 200 MAIN STREET I c�"� :30-4:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
N.-FRI,
HYANNIS, MA 02601 os-asz asaa No Reference R-Red Item PLEASE PRI CLEARLY
FOOD ESTABLISHMENT INSPE ION REPORT
Name ) �' Date J Tvoe of Type of Insnection
/ O Routine
Address Risk Flood Re-inspection
Level R aSe Previous Inspection P A F _
Residential Kitchen ate: /
Telephone (`
Mobile re-operati
Owner HACCP Y/N Temporary Suspect II ess ' IF
Caterer General Complaint
Person in Charge(PIC) Timnrle Bed&Breakfast HACCP
12 IInl(WAVIAL Other Anazs � �
Inspector:�M)A ZPj
Each violation checked require an e na xplation on the arrativ pages)and a citation of specific provision(s)violated. rnvll
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ r
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 6
1.PIC Assigned/Knowledgeable/Duties A
❑ 9 9 ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives s�
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals '
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) u
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
v.
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY I ��
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories L�q
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) 5 �(a
.1 I Corrective Action Required: ❑ No Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo Emergency Closure
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ g Y Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 25.E regardless of the number of critical, results in an F.
Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9
q P )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 29.Special Requirements (590.009) days li non-critical violations. If 1 critical refrigeration.
within 10 da s of receipt of this order. von,4 to 8 non-critical violat' ns=G
l e or S' ��-
30.Other DATE OF RE-INSPECTION: lure P
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N IC' ign re Print:
Self Service Waft Service Provided Grease Trap Size Variance Letter Posted Y . N `^ `
Dumpster Screen? Y N .
Violation related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 6 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 590.003(C) Responsibility of the.Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage
Applicants* 3-302.11(A) Food Protection* * 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated g )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
q Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Pe 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
Equipment ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * egcn�uirzooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 -Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A D in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) �) ( )-( )
Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms practices should be debited under#29-Special
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23.30)
3-201.11 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30: Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doo
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°p SME rqt, TOWN OF BARNSTABLE , HEALTH wSPECTOR,s Establishment Name: Date: Page: of
l OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
M63 q. `0� - HYANNIS,MA 02601 _ MON.-FRI. No Reference R-Red Item - PLEASE PRINT CLEARLY
�p�Fo MPS° 508-862 4644 4
FOOD ESTABLISHMENT INSPECTION REPORT L. _
Name Date e o T o spection
eX O ration Ryat ne -'�
Address
Risk - ood Sery ce Re-ins ec ion
Level Retai Previous Inspection
let
Telephone Residential Kitchen Date:
Mobile Pre-operation °
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other -
Inspector Out:
�. Ll
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS s
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control.
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations��
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health.
r� ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled F] Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal El Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food if no critical violations.observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must g p,infestation of rodents or insects,or lack of
' 28.Puisunous or Toxic Materials (FC-7)(5go org) be in writing and submitted to the Board of Health at the above address violations observed,7 to a non-critical olat .violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8non-critical violations=C.
1v 29.Special Requirements- (590:009) y p - -- -, -
I spector's Signature, Print:
30.Other DATE OF RE-INSPECTION: rl.
31.Dump er screened from public view � ° �� N%d 'v ;, ,, )�
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N L
#Seats Observed Frozen Dessert Machines: Outside DiningY N PIC's Signature Print: °
Self Service
Wait Service Provided Grease Trap Size Variance Letter Posted Y N y(�l/\ \ ��yg� ;}S°: \�f�
Dumpster Screen Y N C
•
Violations related to Foodb'orne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignmenbof Responsibility* 8 Crosi-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* _ _19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additi"vas*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substinces 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F
590.004(F) -
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140`F
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P * 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use
590.003(F) Responsibility of A Food Employee or An 3-3,02.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils * ( ) 9
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3=306.14(A)(B)Returned Food and Rated or 7-204.12 Chemicals for Washing of Food* Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* = Beverages with Warning Labels*
q Food and Water From Regulated Sources - 91 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.I1A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ery crew 1/1/2001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-( ) ( )-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources g� P �'
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirementspractices ld be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'17 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
3-101.11 Food Safe and Unadulterated* ( ) B
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities Cooling Cooked PHFs from 140`F to 70'F
(A) g
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70'17 to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27, 1 Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability
28. Poisonous or Toxic Materials FC-7
HACCP Plans 6-301.12 1 Hand Drying Provision I r 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria* _
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
77
"7--7-
't��` .1•;YapY�t �' Y�t7 gam. �fr, ��ir5tyuw"'y�l _ 3 �>{c'z,„Wr ���`�,�^z.�tM,,e�A.7 � I {� ye ., f � ro � r ��f ��.rn �` ><
+a,. ¢,t?,t,,,_,i ys�I" •1 c•� 'yL Y 9. - ��tl �. +S'tr,j � ~ / .-'� '„
�s.+%-a. s§>x.'�7"•.l.Di' .,y�'� ¢"':t`t �F,r���l;J"''� -'• k'�?�t � 'x..t� w'c �d f-r .<�•.. >s. t t'} .5 � ,. t'
� �'T4`F! -''•atiY a'�,h � � t 'F�': �t T S r r. i R :11"i``S•*'.,.i a+� k�'.:.. 'a' '"'F-" i1--•-•, ^ �.+e+ # ,t s�t d ���r, � .
r{ ]J
M,J?F�� � S �+ �,4� )t_.q _.�•�� ! , �(�'�!p +k�"f, {' S'f� �T"�� ' i�Af.�Y S ,:NiQ '.� '` l�_"K` ti � t. .}AMJ
/
Ikea\ �'1 ':.1�4; icy, �+a '�".'�IIlf��l� , �• ti;. F�A"` t f,r k {tt [[YYYCCC .r.,....,�,,T,m,s - ,( r } 'w�{�i1S.
p �,�? �� 1 t r,F.. 8 '?, a {`.�wt,Hu.{�{ "6+•r q>t i3: Fr+fr - n_.e t' .gl � .' _-t
'1� $ i. ( ._ e L {.i�'+r ., Y•,t't a 7 ,y r' vR r� N
_ '+t,• y "': yoy � aYs Y�T,n ,. -. 't �- s •q 2 •''<.r`}^. n ,ay w .l. jr y
r � .�-� -w.., at � ,.L.t ��'.f t. •s` a; s +' t® w •yt„ ,t +�D P a .•{R ED ki 1
+t, r [- :t,*. `yk zSy a ,'^--a ,$u-. '>F ,.h `-R,.+:. 'AF r. '� t :'i=,F' t,.y - •} a t r, ,p(iq� t ..
"h r. .r r i L r s1 et• "•(�
41�
1
.,� �3' rrt^ ��� 3^ ' ��'l�ka s,� �&� 't " Ff �R � at� d �^"o ,f�. $,i egyc L t+,?�+k 'aLQ�I�� }f•r S .
�� -a .Y �.3 �a -i• `s i-• 'a k:5..� �..Y�*ra°S+w' [ri•.-, xi ! +%���''�" yY, - k bKs a"` -.L 7 �� �' +,
; { tiff id+ .SQL .ra'E •_ w '.�T� it s s' .., r• (� 'r °'
1 �`s � `�� v I t�p�'�•i-`y e. r. i x..,:; 5 L„��� �tSi ��3 4`p � � t r r ��V� .1
�'dY }� tt �it:y � ar A.r�.a•�'+'�t A:A yvis,�c�OA��,.�.�.t,tf�'A7 aT:1' ^cx xt�.�?Aw � +{M�'1 w. l ¢ i iY� =� �_ ���w A42 p[�.�yy '.y�y��.'�' i
^'i+'i �Tk� .•yw r�•�+�,� z n '`1 N + i'';:L,F +' '. ,x}�a ram'»•<r � g-�''�t � •t �`•,^} _ t �a� 'b�� h 1 `f�+f/�;4{/t[� -
#fs � ut t ;i; �;1�'�w"� =r-`,'�a r1t c� 4�a� t '��" e,j�y.�`�,: tv '"r'+ d�' �- a• �. ! L .� .e '� '
�''at7 •-`bf lak��4 �yck, f4 y�.e. "�'�. r�' »L �„'rtt+i j;! Y`�- r' "�e'r• � +?e �' L. -.'w4 k �' �t�`�,,. � ,r prfa. ti-7 � .}�I
t r, E$ _{" a}+ M'< fiw :`^`js -'�'i- { ,v:•� r+-;4+ R,'"`Y+...� �[ .,fi�,�'�- " �„f r' r;aF nR, :+'t¢ .�hk "'°�"-., 1 r e'r t�r++r.. -�.M„�,w�
'�,`. � 1 t -:S.'S --1�1�..�c, 4 w "is��F i - - y,, �a}'.}•,t`c2 � .y �`"k. .,- .S ,,,�. '1'� `u :r:;,a >N Q ta+-+"F'.��' yr'�-..+-+e....'+s..,.,r�,n,...!�....
�5,.'S;'
r { a
aa��i,.
g t ,a � �,. � Q '� , s'Yi's< J.s":���y, s'-•�r '"�"k;�, rt:+i<*a a '+�' t i -*s r 9..Ys+E6.•�'\ ,
.2.v�4}' �j 3<t i-t^�`?�Yva N�.�F yY Zak aa'`s•&• r _ t .r �' »n+ Y» awe..+r•c 's.P�.� •
trry'+,:a
3Y`.6�,f'{s
, y : r°0'og,r �� a' b ('• ",sts°'+F v w�A� �t'+c' ,s•-rk yry^,a !t'Lt k#'+icy, s :t^T'�rc Y`?{'`����...
`�'.�•+ A %[x9 �Yr Aalt ��r'�t•Y S �s � �. # �' � Tlf���+ '•`a :.�°�4tit' •y� �..k a a;:k'� �•'iT'a"'�y{uTj •.•.26r"F z� ?r� x,3 �'t}s �`��4
i .• st„ sa �a�t .�-* t4."i'f ¢.i1Yi.�F,l tw ?<
t t�"✓_sL r�• ' 'R .: 4 -+ Y✓ ✓�. ! `tYai, " t.P iG i ,,Lr7.ya: +t.
s kr x- t 'F` •isy y, � M`<kFt -�'".l�c-�""r'�-•.,. �, [ ,ti �. a� 'r q'�7�i r V'�•, �.t. L� ..a„'r:.
A'�' aw.-=
� w {. p, �.~ iii� a'' .., ,,g•. ,� y' a'}O .�r< �'i»L $ ,'sz,x t -i ,t" z° t
r•�� -,'.{" �""i;+'_"�� .� � �>�ej t'Fl3 "'."t1�'�` �a %r z t } A.; Y .;��� r t�.{ �kav�r� ��eS fit,{ ; is �-,�,J:R ,�
t � { �. °°p"� '\,���3r� 1TM c.,�ty♦ 'N T a ]"r, Y 'y� '�� �� ��t'»'��x�¢ i �� ,.ay.:�t��R{»,��r-•.
} +, '+t y '! ��L+,.•• ���'�"r +°•+; #"'! ,,,�w..., e�, •,�• yy,�, r. �r� a#larott 'a. '`�� �i,.fqe, Y 'N •RA' t1
s J•r?�r6•�r"r.n' ,'� „}. I ii' � 1 r' Fs�yr3 .ar A >r•.0 7y'J•! t r c.•. .-•,vt. ¢ .A •r V1
1 y �:,a 'r�`..• }�'�. �,,� J k rY.±'�' 'k .ri' .f. i-�-'i _ _ a'zfd�Ti i '� S 'S{� � ♦ `•Y
71
Ys,�p�..t',? fy, 'S-,. °+. ;'.. a,. k'[,,.'. *»c• .f?•rr§,�.. Y{ {'y'nr y c: .a a z•1 :�i'r,.',�'�i„i pt �� .i�ti'"'r a 4.�''`a"m`L:- :
sf' 'y's,!g. i i •,ej- s ,, y -::4 a"•.ai .,w ',rvr,,=..-,£syat"y.t R '~f 6 `r ;. } �.; '.4.'+."` ajk: '.rvr it -;cz i i^ir,x
45
t �� �°,. `#S ,a,� �:.., �,r,;�,3 � ;� k �•- r'�•.; �`"`a, S•=s�;. ��c��'',`:_ar :z� � �y�'.:,�i�R � �'4� { a,d �� ��t zi
;j � .S:S§ �' :rx '� i:. • , 'i"Y fi;;1• 1 -�"� '''��`"�ry`hz' �t���• ' ? � •r x ��r? a's.F r�,n-'ftti ,. 9i �,{ �yt�'.. lL�+�,.;�r
!y �� a,, i' �����`. �.�j '+�' j ¢'� 7 r".k�»,.a't' ,�}`� �tx."- r` ».�� ..irZ 6 ^5'i}_ _{ a {tirti+ �,..•.
�, t a �.,? ' ',C" .•? 's' raJt;;,. irb + '...'+`va, _ :er a Y fF Y` `"
f e,t
.a•t¢�- r .-P .2 �! ,jka 'ti: �' .t r ,.y .+'+`d ?h r > -� ! f>.
>a .{'<'i ! ,J t" � :+,�+ '.r. .Ril�a«ltq�'�'° � �. F r:. s � •v J a f,�.�s'- h � �� ti`
#NE
g-m1i4
>ipF e� l+�L': Y ,� O _ 1 i '.�. � • 5 � kYs�ry�il��' ' S+.`' ,'••t-"
�� - rrrr� � >r� r{. '�'* "i.. :+��:.,� �'- "'.9"f�"'e'it -f%� �S ay`�ys.., , v ,iy'ptit�""�� •�i'"'.,.-�i 1_.t�,
ll ,ya �.�t,,"Ja6t"'"' ^.•� '.' .j'"` '»}„ , • s...;, k i .i �4".s +,d ��++L•> r-°�,� aY 2.ft•, #{x _"' {fi �. � P •e, �.'j;`.'e tcr.
f t}�,.r,R4T..fiJF SAS•.'^ 't,.`�+ xAA:k Y'8 F � .: t,k •Y ,Cin -.
y h ar k a t. 5:,� - f P
IL,. .r:��y " a mA .t+F•} as qi?�:: 4
. 11 �}�' ,� ?i` � iL'1" �.t - z •.,.aa? � r .;
�i ' 0.•.� � � R �' X`d ^rY . '.�9 1 .h� + .ta t '{ t Y a } i 4
A - -- ,. y, < 'tnLrTq�.f4� � -.� "� °"+-[i:«2k �r-s:•:..im 1t'�.4� �,•r,x�•yr���".r .�.�1yy�":f,. � 1�i5`�i{ �Sa`i�S�'v�j� �'�-
Y+9,.,' d' Y c h'k 4 •7 w•+o' 'a p •k Y''Z;s
*v��'' '� t"'�'+ ¢-3;e•.i kT�f` ^rst��c,�'�;tea �.• 9 ,v,.X a { �,a al¢�;• r _ �s t �,,awaeyrt �. y r. v a +f:'s s �r ,r's
,�t�a3 � � .;,r #'x�,� E�-'�,••tr �C�,,,` y, yd � -k rr.w _ � .� a y a•�'g <
'f� xt ? �;�� }: _ ` t;4,: a}t�#�y.,Y°5t .�:� � 7. i4�'�t R.r+t�b� 4.q'. �'- g >.��x�i� ti �;�',Ki �•`. J"�+i` .,f..�"$t"
i' d. � a} �* i` ; x i x< s,�t� •�µa ��, i t. L � .n'1"� �m-al�c;. � _.���y'ry,4+w7
N;l.V1 �r r�; *i�:.. �e �fj��� � `� �' .,..,§� ; l�h+erg, �r4 � i�.�. � :.t� a r:z,iz r. i"' ;Yr'�,-.���•L �'�` +'a Fa'ri r ��y'a•'#Ti^a
3ri.rY' 4 y d nx.exa^ s "� 1�-pnr� +, .i. 't ..,{- a a ,• w l-
��,, '�` ' t1gr, � .} rR�h�y� r;+ ^�! i.,- w�.T�,Er .t 'µ'Sr '��'4:+kFf+` � �K�.�f a,Jc t"'+e`�^M,(�� +` o' ��'�tt •; 1.y.; `a
. ,t. '! r - +i.Y.! • s,.t rt'+7ti ilt'�t t' ,�' >''L SY^• ..'�c M�. l ��p ��,.•�f
} " '.x'i ¢A: rs .�.. , w e. # S"'►.'i•+.7'y'ri:t �''y'* +[;- d'f! l �;'. "kitl-i..,
b 1,•g4,,:,zd ;C }��t t f. .`w'Ly+ rt, �:w r *.r.; b � ''^�..,y,�a''y� .t' � ��,�.+''*r
r.7. k.y..
Av1$t'�...y,;. 'Cs, 'ir�y#t.3ttr,g,afr' a„�".•• n?>�`�`�' "t'f-ni' ' :v +ar '.'_e�4 3��{- � �'a � `�:-f'Tl}�`- �i� fir. a. 4L�a'�'',�. -'tr v x .f,f�_ ,..r r� i
t �.�i) 4r Y. ,� 'Vf 1!.� �.- � .. � XX��,k • ,'rJ y-'.F• � ai
'L+;,* 1ti,,s " . > �a �•.. ' ., '�, . E r •�. [ k R+.,�
a l.i.}y' }eo♦ }:�A *iy,y` .'ti'».. {k'% .�vf •+r a ,F;'mt,h-�.w'.,P x... .. Mrs^. t-J .L
� d Y �n?'..¢my", •2:..•,.r i. x ir'� ¢f � �, a. 1 t- �`� �»:: Y .f• r.� > �?.-, -
�%+"+�R."13Y%.i• s� a; ��rr�y..,�,s>.wR��y�.-� �''E'-4. : '��^+s•�'' „k' w5.'^i �3�e-� �' �sb�� '?y:N iy'.t'��
�., .sa cM _•^c j'yq-m`rW� Ye SS«Y _. '1Y' ,,,1>ti" �•vt'.yt A +�� ,> s.[xr, =-y Sa*i~i. x.k... +r•-, TV
.
,fit Akre• 6.iye. !t j{' i�,/•` > a..1T 'F yG7` �N' i c�'pS .T i.-.3" 1}}+i.:. ���' Y.fi: }I'tea%r /i} �'�'.L Gk�E-.. % .'M• ,.F ,{k j� 4'��J��.\_
-.i' M1aH Y.476i 1{ '_ ,j ;rf 1. :tt ! {.�Cr.-- A YY �{ A. { k? /'4 yr..f' '•,. 4 e_
'�s�Y 4 v �'' ~ ,4•�+: :-+- a.K" ,4�lt`r � �,i:;f ✓ a.' ,. �''�;'£* �,��j��",`�:. "�`� a*dw,�y�i✓e Y,-.. t;�tr� ,'�,+l v:a f.,.11k:.. �A.+�;-s. +�;'.
ri,
'{ �' } i� 'v gar�• ' +ea+t••: ,xX.��..t ` ¢ "F. �'' -� +,t` Y u " �,*� � Ar"< u ✓
...Y " ..� �...y t � l.w a, -x`,: J}" t: :� r r '' rR a"" 4i t i { •[ \ � u y ♦ +k�' ,•x fi� '�1����lri �
".. Vi•,;1`• � ,r�+..:(�{"•4•! ii° L °t'>�42 `�'.�JS�z�..•'1y d � 'r c• �Y t:^TM: + /�d�'y",�� y �}`;¢1 'fu:'vi�4 �_V�' �eff`�-}7l�e-�'i A3 `S.•. °����,.� ;� �.
�,'�r�s{ •� t [,•¢ � ,• �'-#^""� •x'r ' +#�'�.�N �t prFac°a.• � k;.as9 ��.. '£ ..^•g. '�ffxu.;•+.•t�^f>
1,. �r�~' ' a.-*' �yc' "t � �S'af*`7nr_-x .-:. �j y.�'3 1 }'{ YS<> M "� �° �r,1 , --.., •..
4,.. ¢�,it• "'� J'•Js -'+1 -s ¢� y+',vr��v t � kip 4 +�y+a�"= `' a � �m�' � xo.'
� t ` .,. t�'.A.L..y n. l �'gT 'r'y.9!'g .i d 1C { F" `�i.w +" '"tj� �S ,,k:. # -✓ +t F #�
':1zr4, .. Z' �„•,,:r.,.r ''. -sue r.+.,-+a;,e+�'.+ .� '",k.,..5a �",'' ,''�% 'lkx �r�'�gv n.. t 'y"�""' pn'� yfi,.�' >a�'i!`1 ,y,I'' ,ga ,`�' �� +�F" " aS �
•.f � -P%��' "1'i" 1 ,r a E4��"� -.. 7Sga, rqs: ,.'n'2^+k"AY,a","�'p s4x: '�of s�'�^*,-�ie�'yavG`"�� L*ss w ',� F�""�•;a
.oa
-a�. ..r. e , tJ �f L � ! +pt'i+ -r �;•a t '�. -� ,sh x � F �'t r �.7! ql
$ ✓ .X„t*s:.y +s r^t. �- � rw-.4 „�', ci+'A,�,r '�# ..'L t+ '+c...` �. a1 yt?s
T -t '• y n rr. .: - j�'h' Y �kg J} Z trx Yr .K c'.+
rt *fi. ♦ � f`dr,y, �`�� -f y+ _t t - �+ nY. � x[j7.' [�'y 'F'. y4r• s J. g� R
... !y„', 4 I} ? z`*�..k � A��• wa -sy a ? •"; 't `aa '.P•. a ti}v a ,1 ,: it.
ti'''*' �h .c.7r ''iT'r a`•�,,,( Y�{Ds�% °t,� '.�i i fir, -'i`jn. " - '?f �e � .1� > t` �4 X'z`}'aE,1'E t'[ "' +' f+e L ',lk r� - -
Y h�:: iZ. ^� k �" �� k ,'!;..� �A�'.�F t�i hY,.++h. .. 2�• � fi. 1.. -1�3. t tk y 'x s ,t+ti•.,w'r y','#L b+Y� r 1: � :v
r •
'��*�-.:•'r,a�-`t r„v� �v�Q�t' ,�7� i�tj"-�o�������� � �'',.2�5��`+ 5{IprwR�� C k''F' "at' ;' ,�r`•I"$9 .`��.yc.r"�::�a R �, �kiRF�•a,,, •�"
: � !'� � '�'"{ ��1�P fMlz-,ti i,� J yj Y Tar Y, "5}n4 1,` 'r R4 • E
�G� � ?r��Y R��r�yy s �;,sl��i�.{,r �`:x e4 , : -�»• �'M 2d`ifxarl.•i �+ N:.• �°•. � _' 4 S - �.
� `.�"•� {'�k S` �' ,y�i vP:7..Lt'"�. � r r f, �•'�'#»;,� Y -i¢o S,:t� f'i ,ti�:u:�.� i1..R'�:. .cT. � -y a � Lr � �.
` r d,k. ..},Pt .,'3� �-v r, ,>: •��^S 'a{,µ;•Y2. ,�45 i, .p-t r �� x�.{ iC" .,�•:,rn t. k•Ia• -` rfr � rrjA";;�``4 x��,} #1
r.! a .-� '""+ '.:k .a �L.- y, k`'Mk:l# wf„'rYY;.y 5 -7 �'y, ac x +}r«y:,.i .ae 1.t.2^ L 'r. t^tr a+. T¢a x.' t • a,: 'X w V`
'} t.. t_, t< vn,l,,+"4t��`z,rr'�� i. ;r•t .x ,t_ .u�..
i` i.*r^"x�ris �' � � �� t4 � 7 �7flta' 'KrY? n '•#.Z+.
# ,trw :.. ;C 3r Yt if r¢r� a �C•$5vL}Y`�.,i[ a r' t:l��.✓i„'""'4F"k:'= iRr•+R.? � "'... ""r:_
x i,ti'• �y ¢�'f�al'a�`+s�.t �3ry,*a'sI s}.:..•,N��• 't-"tlr� e,,,,yao� .: a ..""'.e»as.�,r+... ' t 'tr�s +9.•: r •R },."s �Sni�vr <i
tr, `.' r. .. �',,.� •. 1' '��� 4 > ,� 't� ra` ,;, { �rr *f, o�'', t # ✓,rt2 : �r
a j.7L � •} r'.:..-a. S 4.7i'7r .tr .• [„ wA a 3w y. : r `�i�.. t. `�' � r i;.:i� M1 R"�� � eta r ,y
wa ,• }} '� ,a��,,, , `'- �Yr^'�r t a [. rr- t 'Kr t'b?' 3, 19f y! t!�"G L.rrv`L ek` �''7„�
ii �'� ,,, �" 7L .+E..i a"•�.{"''s 4 '+y + ..
•y� ,L � ,.t a? � '�ca�,. ''+�+i �a '�. k"� �sY
'C' .s T ;c'iii iT.•. ix'� t{•�,W Y.rv 'y �•�� r '.b r, t s, ..r n#. Ir• }.F Lr ,,4•j ; „�. ,
•e+��' yylU�r�„rY�[x.#9g'F r.-fi�_�`�-r4 r�y:�IT
`,..(f,3" �z'Yn' .ty�,-.q�!Ym �<I,I� �{tL' r[.fn n >,: i ,}.1. �4+ t1� 4 +'x. i>x Yi•.
�.�"�.*► iY'fE.y,. ^�Y.•5pirx:.j �aaY�"�4 .�. ¢S y i+�•' T Ask M� 1, 'hK d4�j1, :3� :E' �ly� � � }1 �,., ��"1."'$2.^'L` i f Y 1 f 1 ,�.
.i';p rg sy,�w� L'�u? ,7 rr. y�++'tS r [. v� e.�. ".`I� il4 •y,''�4 1'r-# f"n� �y{' } 'may 1" a4'k ,'
- �:, ;,�,�.:i!r r.'.. yy..� r � fi-�."`p' dd 'c J'�"e ,a e , H •�.t�, •,�, rr. � 4't � k:-� `' � ++ G + 4,• i �. 1r•r" �'` bs
r •�,ruE}'�rx� � 7K 4' a•.� �i+.'%� , E:� y 5r a!F!�, ��•! y :^`.:-YX�Sty ;*. k :. r i""''w i,: �t f4 „r.'� LT l y<,
a x �;y#i�#}r ��,. "#�:�+` t* ..r'7" n}�A� i' 'L," `ca e r, ��y yc''y+`�cro-a :��'�r Y t .; ir••`t,_E7P� si• y,�•- f"¢�:�yam,, r E �sr"�a V,�tt�, inw
ci r.,,, !b. .r' ; '�. ..r»'t`', w' : .h „,�4„''r 4. ,� s. ,a,�?. t,'a ¢ h.;x_ m,+± ,t .. ,+ Y. u;, r r .•� •:
}•'�x,..# '� � a f ,�5 r. � >;:Fy"� 4+�� •�Es.fi�z rr.-y t „?�,. "1 � � :tY-f��l..., k•� ::>,c.�
:he: Y $ 1 � +L' i z �y,; ji �' �" ,rW}'f F• .ta{`i g� :�'s Y' �l:',l' e+ - i'�ra.r t+� r. y r r rt ° '4.
a5a:- ,i# r+d .L1y Y r 0µff:`3 t�,!�" q jr. i`a i1 ;�. .< S' +{�{� L �0 1 4 'P� yt♦ !!�� '�• + '� [J`t w n
�'•a4��'3�r,;rxF`'',q•4�,i{77'y{'.�+a`���iv 1 >.,�1 �. ,'� '* `Yt� 'Y 'e� ; z `{, 'S '• -«f Y•Ct '�r'� 'at6 �s�1 r�F��F {� n '�+ e :-`a
r'r.,[`�.y ^•-.Y� }�'Yn"L^s'� r Yi} 't ,+� tt e,'. y,.t',gy, 7 'tr,'[ti.�- ,"Y' L {T<t ,.7✓t^ f S�,c�� -}•,rt '�ti:+:'µ,me t::r,.,'t? p�:
�$ *°�`,., �"• c�. � 3.�i •:» F � L,4�;,x''i ���„' a�'" � #•i- iYt '�-�r�'. .a it
,saE�, -
#36<i..¢�m� ftrk'� �'.e+r arl. J rd"� 'n4�.�ta.4r*�S}. 4 � ,�4�•�1 � rw� ;itt' n " r �'' f �`' �,.a<it s. `ag t fit
"'�•;� �„ 'k.¢ t 'F w y� -'" r .'1P�,+ •L r`Sv ,,• "ry'$, a +ht ,,,>. a. "t *}` i^J
�,C - S" 'tr.t -.,�;;,wa� dry'�.!�, a`Y,si},+ wA ,,t'�'.. ,r •i�rF...�� •n't r I a•r'�"h•F . -t'+14� i
:::� ����ff-.,s?c } .s• r.:.,,;,K iyi,,. '+'.yµ,',�cr":Y �,?. t�: a q��rv`". �5,y r��w•�3 :cam '.[f�,°'�'��','t �t�T'*�}; �k+h n.�`�.�
fir
Z,, �{KS° exF- ".'s 9'+. ''a:: is �+lr 4 'v'""+r"Fa E•�'`fr+Yl:>.`•.17 S} k:t� x n r- ,} k 4.a "".� w >. 1 2 yP'«;;., s ➢" 'r
_s' a;`'# ,y1.y" '�,c q{�` ( f? ;•",,`.�Tna .:{xi,J "t •r;•,.- 4•P a�3 �+ i'pRi
'' $9✓br sr�+it X +, ^'•YDy `{!x.: ]•{ 'b'a ',..n 4, '' t Y 9^p• ' 'r`3 w .k }RK +}:Rt ,C i
k�7 t �.-r i� -..w a �*' '�Y. t �'.ss x, ' F •,'9� } AT.�'r x ✓ 4`?'•t�s ,q t���,' _ r yip c s •rJ o z�i
jr s� '?. �t v '� s' ,j't'+,�� "ri`u. •�' 1•T +� -.>,,j+L ,1�'x�+ :�;' ti ';' �a�h - vt ti r 4t ! � } � t.{' fi d �t¢� i�1�3 ,� �u.,.tl�yr
.'S't�Y r+- C•�a`fir. y�, y ,e'•1�. -4.�r �-�.: n .a. ¢�. ���. t t c T F •C stL r� a 7i s. ,a r,. 7, .. �
"'�" L `P"a*✓§ a°T'�st+lit ,� it .� t�Y;S i t;�-�< x x y 't''%trx`y+ 1,G, a.. a <.,, r� � w ys, L !» r �' ✓ s.,[. , ,. ,,,r
J+e�r �'r�\+ --.e a+•C' ,,.. h •�s"w z r.Je}-e,+ A 7 "w �rr:lan � i7GP,� { � ,a y 3r., 'Jt r „� ; ,•.s�.i,� •,?�`7'=• ;t->< fI+
• :,a�4 t�t; -� r a;�, v Y n�'c � '` ta,sr �2 -.rr~F Y;" i- £a _t_ h ��: r jaA+ `>< r �'F# t, t `��L,►a
ar✓ +- a # # n y�� 'r%. 'A'a+°x fi`*M �� • "•• s iY r h { } ,. � z � z �r�WV(Y�,
,. �u ,> f+- rtrJw�"- f.'�h�.,.,}a .*7t`"' r e a ryy5 '�e!F } a r rtY r M 7�. kFx.�v:� r f1.s.k ,•".L S[ S "< p !
! Y ,. W .>„%` l y ai..0 Y•1 P.,+qY, !x T�k�t C 4 1 X FV`.. y}f`r dt `a ',? ! -.T iM � � '4 T :`.p )t SY �/:� } .�Y:
r;�.r �`it Y2;:rr -'! .x. r:3 r f+. �y a� S g�A-' '•-, ¢ ' s ': 7 i•. ✓ tr n.� '�`
- s+J �qt� y..y:"* ,��..�th f �`r t?` •tt Kh y,. •ax +�#'.'t^�3}2�rt S '.,1�r+„ c `.;a' 1� q.1'" �2::t t> l..i.,Xy i w',i4 ri
t._ F. F` + +' t P� +•+#'•,.aa, �••� 1>. ILrt - t .. ...+rn K 4
� '� ; ,.Y d '�MRrAe, to ''? "Le t .. "d .#'.,.�,1�-w:; a 7Tj r »Rn r^ ♦ c•'1 t !` 2 to -: t y i 'f`.rr wr
,� 5 k ,+ 1; .1 '� ',F 'J¢ e »,+ a :'S• a } rti w:f y." ti!, wR 3a t •>&:: r +:.. +.:. ¢�� � ,;8 y
yr „' i¢,.� , _, n.-7i a ! r � •R,.,y t M1 t }•. ?r ..�t#�S ?� < y�" -� T, r�i r -'n4'?' '�4'i.,;w'9S,'
' fi 6 ` '�'ti,q,b.�u J�,.• � �+,fit^s {�� h� i� �,2 t'�• � i. "�, � �-:i�[� �"`t.� 't�"�.���/� 4..:,rik
!kr J�'. •yt F-J ;k ,l�s>��,1�r'{ Alt " � , {Q't :h �� r ko �+. rT �iL�•SaYi�'Y �I�lTiiXe �q t.
5 - � r k �,� s" t d , .r. R L"�M+'•ci:a�� T� ��+� 4 "Y A 4 x #'J. x ..��, L s+ ''u1 :r!a /i.�ffv*7 4 A[�F"`f il`.
`:�-aa �' ✓ i �` " .tat 1�3: � �� ti [ s �n�z .r f +. tr� •r^rsr�t�'�»+L. �Sr� >ai�4�a. �'��`-„� ,} fr _
�r g
i' •' t Y r72 A' .c //3 * 2 t: V �'� ,�, s ^•1`d ' �!. ,r`
'� i � .•!h i-ft .y:.� �i! LLt���yyy,,,` <I!':.., p *: 9�,y.1,� J I t �.,+^.ttr K•a T`++ �.1 ,'Y
ti:?� ♦ 4f'{�. + ! ���; A�>•'��,�,I��'ni�al t'V d Z� 'r '"'Ifk". F" ¢Y^.{F�' '. '. ._ P' ..7 •5"+. * l .�� 'r.' S r..
� - `,+ -{: _ r _..{ _ � ,�e< f iC N�''J 4 d'' d,. `'•. ' I`'.'4'•t � ', a r:,t
+ '�_ , .4 • t� '' i •.� �J1.yw a «4
•�ee4 t:rM•S. t�:
Town of Barnstable P# S R t
y� Department of Regulatory Services
Public Health Division Date
■A MAPABGE, ..
059. �� 200 Main Street,Hyannis MA 02601
N
.tom
Date Scheduled ( 6 Time 0 M Fee Pd.
s
Soil Suitability Assessment for Se' ge Disposal w
Performed By:• Witnessed By: ,,'. Ml
LOCATION&;GENERAL INFORMATION , hp
Location AddressQ �j��t/„� Q�� Owner's Name W,/, G`'t�„
Address F.V0. W IV AZ'jot
Assessor's Map/Parcel: 11
�2,Z Engineer's NametJ�r✓a�
NEW CONSTRUCTIONI J REPAIR ✓ Telephon# y� b •LJL
0
Land Use GO�� Slopes(%).0'3 f° Surface Stones Nfk
Distances from: Open Water Body yob ft Possible Wet Area Drinking Water Well ft
Drainage Way ft Property Line ft Other Ne�— ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes-&pert tests,locate wetlands in proximity to holes)
1 " yu
—�' 1� ',w�. '� C"r'`��"`,,�' ✓ f � � �� , ^�� fir,�r��`4�
NO
e
f
� 3
Parent material(geologic) A- Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: /Vonp— Weeping from Pit Face /V IN—
Estimated Seasonal High Groundwater Zk. (C4,Z�ieE_
DETERNIINATION FOR SEASONAL HIGH WATER TABLE. s
Method Used: fl ... ,. . _._.
Depth Observed standing in obs.hole: in. Depth to soil mottles: in. -
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date",iI 111b Time U
Observation ..
Hole# Time at 9"
Depth of Perc a Time at 6"
` Start Pre-soak Time @ Time(9"-6")
End Pre-soak vY��
RateMin./Inch �Zriyv� t.-, `
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To'Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q ASEPTIC;PERCFORM.DOC
DEEP OBSERVATION HOLE LOG le Ho # .�%...
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
Srv'�1F.
ON y) z
coacr Ink f
�I
w 7�6-y 1
�rz-I26`� C-1 ���
DEEPOBSERVATION HOLE LOG Hole
_ �
Depth from '+4 '' •Soil Horizon •' Soil Texture Soil Color ,� Soil R f'1! !Other:'
Surface(in.) 1 -•;x R .;•" (USDA) . (Mansell) Mottling (Structure,Stones,Boulders.
Y
— `' ; ., ` •��'+ •.Consistency..%Graven
t •(�^�,�, /tip 1t,-."�`_. �:Q�-.r f � R�.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
"�� DEEP OBSERVATION HOLE LOG Hoe#
� .�. < ... .., .... w .... . ... ... .
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate Man: ('
Above 500 year flood boundary No:.. Yes
Within 500,year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? -
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required tr ining expertise and experience described in 310 CMR 15.017.
Signature Date Z S
Q:\SEPTIC\PERCFORM.DOC
t
-- J
J
No. B Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
x1itation forn1upgrade
rpstetn Construction Permit
�- 9/
Application for a Permit to Construct Re air Aban
PP ( ) p ( ) (!f don( ) ®'Complete System ❑Indtvtdual Components
Location Address or Lot .379 Qrkgr to-,A,OStZtv14j Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 1 Is-Ott T (A J (.LV5
Installer's Name,Address,and TO.No. Designer's Name,Address,and Tel.No.
Gm i�+�rc.(.I,_,5Tc_1 S 8' 3d,6 5wowMW FNit#lgacw4;%MIy+1-t%Mfs
8 .S:P6_ (7s .mil 3�65 t; So$-Lav-3,54
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building'To%%AA7 No.of Persons `7 Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 35 gpd Design flow provided 3 y 8 gpd
Plan Date Ql , LO I'7 Number
-`of_sheets Revision Date
Title TmoS" QGS�' $ Sf0'R``
Size of Septic Tank ISao 4r�-Z Corkft mm .F Type of S.A.S._Z�$b0 b_�(Mi�w► 12�Io x ZS,
Description of Soil - Is,so (.NRw%
�'`Z`I CM►�It6� Cuy�� S�ArM'� ln`It S���
2 5-SZ" C I c t4vC(� c_ or ir SrAM7 j"k 4 I f# S?—ny" Ct tot*tL two 501m) 1"0.6� $
Nature of Repairs or Alterations(Answer when applicable)
1ZCQ`�►� hetdl►w, .�� {ar C"^-, WN tr%
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certificate of
Compliance has been issued by this Board 0 Health`/)
Si Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. --,5ql :2 Date Issued
No. ;JC 3�7 r Fee 6M
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TN .,F BARNSTABLE, MASSACHUSETTS Yes
OW
2ppYicatiou for Mt;_g" r
o°' aY pstem Construction Permit
Application for a Perin o Coruct( a p �ade(,,�► Abandon( ) �,eomplete System ❑Individual Components
Location Address or Lod Io. k Owner's Name,Address,and Tel.No: s
R Assessor'sMap/Pazcel 1C 4 �h"AJO CC'T5
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.„
C�rvc C,1 ti iiC-i jC8 5_i.6 jV4llVif EM41Ojec'NA10+ Z*A`ydttll�fq
I C= :P• 11 li r\C� as U -H 7 -_7!,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons r-7 Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 2,�C gpd Design flow provided 3 4/y gpd
Plan Date k, 1-7 Number of sheets Revision Date
Title'12_ c1 .
Size of Septic Tank k5,14 f'x,._titer Type of S.A.S. 7
Description of Soil
�`� � ! z�4•,�� ,1J�.,� chi`.►� 1�t�l�D c 1 l 1
y C (�1 1 w�4vll, /„�nAr cs td...� �l,V 8< ! �_ C7_ 1'�y • (� ! �11.1t Mr-alp <AAjk-\ Itet111 r f
C � C C G�^^ R j�T6 i-' V1-� 6
Nature of Repairs or Alterations(Answer when applicable)
'i7,,\4"� ha1
1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.Signed /1/� , Jy Date
Application Approved by 1 Date
Application Disapproved by Date
for the following reasons
Permit No. 1ti Date Issued j I . ci^)
Svc t! r
-------------------------------- -- - ------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that-the On
^-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded
Abandoned( )by
_ at � �E-��,.*� ( „� , _ p �. lz.h .been co"n"srtructeiiinaccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.0 p I-L4 j I dated 17k) 1
Installer I' ,<r' t \ r t: g 7`� r (_ 1 m 1
Desi ner �< t i �� - n r,
#bedrooms A"4 Approved design flow � gpd
The issuance of this permit shall)jot be
construed'as a guarantee that the system 11,fiu ctro a d'e s sl ed- f.--
Date , LI / / ;r Inspector
1 / t
p4
No. !�O "� ) t _ ..- Fee Q(�
�Y THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTIfDIVISION-BARNSTABLE,MASSACHUSETTS
misposal *pstrm Construction Permit
Permission is hereby granted to Construct( a)' Repair( ) Upgrade(.,,.)— Abandon( )
System located at 9 x,_.w-ter
and as described in the above Application for Disposal System Construction Permit. The applicant recognized His/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three yeag'df{the date of this permi.
Date (� 1'�r7 ' Approved by
f
Town of Barnstable
Regulatory Services
Richard V. Scali, Interim Director
&ARNSTMM •
� Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: fZ 1S Sewage Permit# 7 Assessor's Map\Parcel /� 5- ObZa,
Designer: Installer: 13�
Address: R U, Address: 8 �o
U,"
On /�o�CU/rj ,jrvice ,HC' Lcal►�� was issued a permit to install a
(date) (installer)
septic system at �� l3A.ti �STr�.��L� based on a design drawn by
(address)
81.A kk E 'Aces v\ dated lyou (it�C
esigner)
✓I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-buih by designer to follow. Strip out (if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compliance with the terms
of the IAA approval letters (if applicable)
r�P0"OF 4448
G
(Installer's ignature)
S I
( esigner's Signature) (Affi esgtioltamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
�t3 S �b✓i p Q rn r lr`o-IA� -1q(e J�
No. Wt,} f�rezl Fee
OT E COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS es
I ftpliLAtion for joispo8af 6pstrm ConstCULtion joermit
Application for a Permit to Construct( ) Repair( Upgrade( Abandon( ) E omplete System ❑Individual Components
Location Address or Lot No.'Y7 q o? rlk kokkA1Ft5f Owner's Name,Address,and Tel.No.
US`Nerv.11� wigrw� C\v1v
Assessor's Map/Parcel j SS-o 1 o;:4 wt1v
Installer's hlame;A-,A and Tel.N ,568-1126 3966- Designer's Name,Address,and Tetl No.
d.J,�!'C� $ 1\w�v. t-v��rcerr� k Co.au\.
�"�� ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(4/4%)
Other Type of Building V3z\e-\- No.of Persons 67 Showers( s Cafeteria(N14
Other Fixtures
Design Flow(min.required) 33S gpd Design flow provided 348 gpd
Plan Date 7tce,,,,� ,I Number of sheets ' Revision Date
T
Title (7rueoa A ge- "xs n Sep�iL
Size of Septic Tank CSdO CAL- Z (orn,et_ Type of S.A.S. 56b "k (Y�,,. �� 1L41 4z's �e\�
Description of Soil �-ig� 0 e, Cc,kv� 10`& y
(AAw17 fops tby2 �l
2�-LlZ C` Mey %pt,,o Icy(("T1Y
Nature of Repairs or Alterations(Answer wh%n ap�lZab% rota S-4.0o 2,5-f 6/:5
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code n not to place the system in operation until a Certificate of
Compliance has been issued b this Boar f Health.- 3 _/ y
'�
Si a Date /
Application Approved by Date
Application Disapproved by Date
,tor the following reasons
Permit No. Date Issued
No Fee
Entered in-computer:
THE COMMONWEALTH OF MASSACHUSETTS
. I ��es
PUBLIC HEALTH DIVISION - TOWN OF-BARNSTABLE, MASSACHUSETTS
ftpliration for -Misposal4p-stem Construction Permit
Application for a-Permit to Construct( ) Repair(.-Upgrade'( Abandon( ) Ejf'ornplete System Ej Individual Components
-r-
Locatjon Address or Lot No.';7 9 'parr K Owner's Name,Address,and Tel.No.
Ui�crvktl� / vqr_ o 0%)\0
Assessor's Map/Parcel 11 S.o g-7 I-4Z t5y-C,-% Nce khl )A A L�P o e'-k W BN<11'
Installer's Iffne,Address,and Tel.No. Designer's Name,Address,and Tel.No.
'j-
A"ka F,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(w
Other Type of Building No.of Persons—(,77 Showers(tpi Cafeteria(,via
Other Fixtures
Design Flow(min.required) TW gpd Design flow provided 34 A gpd
Plan Date-j'kt e,\a I (o Number of sheets i Revision Date
Title � 5 Sep\,,_
Size of Septic Tank 1500 CAS- 7- (qm,^Ay,.AM Type of S.A.S.7- S(it,3 (o,�k 1, 4
Description of Soil-T-Aci 15,119 6-10" Ok SWy C4Av---. Wit 4 ft
I/Y
Nature of Repairs or Alterations(Answer wh4ka'pTfca.Sll) Z37-Y (,f3
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Codee o place
7-alnot t I the system in operation until a Certificate of
Compliance has been issued by this 13oard,;of Health
_01�
i d!
�,,A46 DateJ
Application Approved by Date
.-Application Disapproved by Date
,for'the following reasons
Permit No. Date Issued
-----------------------------------------------------------------------------------I--------------------------------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded
Abandoned by
at Rj has been constructe in acco nt
with the provisions of Title 5 and the for Disposal System Construction Permit No,4� )1)
Installerli-_-'Cr "Qcx_%ST Designer
-#-bedt,M5-msbA",o (0b. �,e�� Approved design flow /Z�Oj_ Lynd
The issuance of this permit shall not be construed as a guarantee that the system will nne johl as designed.,1, �
Date 3/-? 1 inspector I V'
------------I---- --------- - ---------- ----- - --------- ------------------------------I--------------------- - - - -------
No. AN� Fee
V - , —
q71THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
. Bisposal *pstem Construction Vermit
Permission is hereby granted to Construct Repair Upgrade Abandon
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co pleted�vithin three years of the date of this pe it.
37-,--- Approved by Date Z22
J '1'ovvn of Barnstable
Regulatory Services
s�xrrsrnatie. Richard V. Scali, Interim Director
9 "'"9.
i639• Public Health Division
'FD
MA'S
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 3-8_f'1 Sewage Permit# QQJZ-'1417 Assessor's Map\Parcel //5- p a a
Designer: So,l[I vr F A c toot ce u,,,S Installer: k f-u c r �"((�,,-C�l�',.--rc r
T
Address: f ar R4. Address: 8 �
d�Sncw ��e�(`i� a•b SS �5 ery t �C 0 S1S
On 3-3-/ 3feucr
f 1hca lSTc-, .was issued a permit to install a
(date) 3? p,,��t`aaller)
septic system at /53 A,Jm5' -6-77- based on a design drawn by
(address)
su��t'vc_n -V\ t✓XCC(k X dated JCC_L. ,�,C)IX
(designer)
t/ I certify that the septic system referenced above was installed substantially
according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any-vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed 'n - . pliance with the terms
of the IAA approval letters(if applicable) ��,\�N OF Mess
or'_�11 yG�
o
(Insta ler's Signature) CD ``' L
No.4G i 63
9 9CG/STER``�
oFFSS/ONAL
(Designer's Signature) (Affix Design re s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUH T CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Certification Form Rev 8-14-13.doc
---- --- ------ -- --- - ---— ---
Goq Covasm- 1A9ia6*,,hcC/.,6=311? IPa L,/
A TOWN OF BARNSTABLE
LOCATION "I �Ry ST — 0k( GarPCouric SEWAGE#'.-c�of7— �//
VILLAGE O: (ery (( ASSESSOR'S MAP&-PARCEL //S-- Qaa
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY b-U G oZ=a rU ,1- ^
LEACHING FACILITY: (type) 6bo&4 ['fyWili e (size) /9)CaS'
NO. OF BEDROOMS
OWNER Zy, •W (/, ,
PERMIT DATE: COMPLIANCE DATE: 7)Ec ilqa.0 l
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
M e�CaA Fr F,„tic�
i ppcoveel
010
s�3"" — �{ — 5q�6 ,•
0
0/44 6
/7t/L1i C,'�T'�il C"!�'1,c'TfL>r`J
112.
r
r
� �.. t/p
rlk
*--•--------_,.,fr � � I �•��d��,',;, I t.�r.>dr7" � �,�/S' fly; J � .,3 s
r,� „ /a: r
� .z ram., _
I
7}` t
t
J 4 44 ,
r� 7
-lii
i �,.,^^— .�.r.._. - � v.{ � i ._.. 1 � !A ._.,.�....a-.._, _.,....,,._.—i--r...... ,y.%._..... .r.--..,• t t ._, _ -^-....�.�..._... #
1 /7
1 " �------•-- -Ni
rl
AL
:_L�dl �� f ��i ar...l � M.e d•` .v`� i ��FT.'....i;., �.�E✓C.Ff:.�--` /�;... J'' //.�3
___ _ ._ _� �' '=`5US y'"i//C-- YE'�E'_/�S-� �4''� f•CG-tv c.�i�'�.--°�G,v T
1 .. ..— �___ _....,�_.. t�= ,.___ _� �< >^✓c�-r .�M�w�,1 oaf ,®,�.,.�
frS"i/
� __1�✓�7"�.� �r�./ .�.c�c..o��,�->�".a'f 7' — 6aGL G��U�1 r�.:cc�;_,S ��¢ ..<,�3" &'�. s�-1,�'L`�`
�. �—L7l,�.r G� °�..°/4.�J�` ,�`, ��K./sue`�•'� �Xd,``7"/�._� .1�csru,t✓'Jl�',�,#�'�7�� .�' �>Y'++��"1�Gr7V%.,� ®.,._. w-,...,..,.�..�....-..,..,.u_„�....._...-_.
f?/T;4 — `I C::f
i
I
J NA
Marjorie
G Lewis
ar orie
10,
/� w �
Fairway I l /����
v,
_
_
d {
_ d
z
J
R
............ ..
9
1 / Out r E...._-
/ "
�� � t � � �� .� � �.,- .gip, � .,k •.«- I
Rough « ■ j.
''........... .
0 1
Location M
...:....................Outer Ede of Rou li._...._............_.......... W
oc tion a
9 9 �� -• , 1 - 00±2,0 ,
............... I
I
ASSESSORS REF
i f
Map 115, Parcels 022
ROPOSED
Wooded Area - �. OVERLAY DISTRICT.
12'-1 AP - Aquifer Protection District
:.................. 9
P DO BOX D
;n PROPOSED " / r =� _'' _ -"~ PI�O V ZONE.
N SEPTIC TANK
Proposed Overview Sketch
s1'=100' RF-1
p New
t . `- Storage Facility Area (min.) 87,120 SF
00 ; ...,t 7776 sf 1 Sty.
Frontage (min) 20
TH-1 EXISTING r ( Building "C" Width (min) 125'
TH-2 HOLDING TANK _ / Setbacks:
._.............._ ....... ABANDONED OR
TO BE
Fron t 30'
..REMOVED 1 { Side 15'
t✓ 1 1 / Rear 15'
a I SEPTIC NOTES
�Xlstif7gq / rLJ )
11 sty w f r l DESIGN DATA 1.Location of Utilities Shown on This Plan Are Approx.At Least t 72 Hours
f�J { Pumping Records<300 Gallons Per Year Prior to Any Excavation For This Project the Contractor Shall Dlfake ■
Re t-$ Xs°n - New l /`: 300 Gallons/90 Days=3.3 GPD the Required Notification to Dig Safe(1-888-344-7233). FLOOD ZONE.
Storage Facility / /./ 3.3 GPD/0.05 Gallons per Use waterless -67 Users Per Da 2.The Contractor is Required to Secure Appropriate Permits Fromm Town
e /❑ 2184 sf 1 Sty. P ( )- y Zone: X (Minimum Flood Hazard)
Agencies For Construction Defined by This Plan. Community Panel N O.
Building "B" I Park Toilet:5 Gallons per Person 3.Wherever Sewer Lines Must Cross Water Supply Lines Both Lines Shall
/ I I `V 67 People x 5 Gallons per Person=335 GPD Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to ri'250001 0757 J
o
Assure Watertightness. In General Water Lines Shall be Constructed in July. 16, 2014
j Coordination With COMM Water,and Shall be in Accordance
i I f Septic Tank With 248 CMR 1.00 7.00&310 CAM 15.00.
I / 335 GPD x 3(Commercial)=1,005 Gallons
4.A Minimum of 9"of Cover is Required for All Components.
r Use a 1,500 Gallon-2 Compartment Tank
E �•� 5.All Structures Buried Three Feet or More or Subject �
to Vehicular Traffic to be H-20 Loading.It is the Engineer
LEACHING AREA 's I
/ Recommendation that H-20 Always be Used.
/ f 335 GPD/0.74(LTAR)=452 SF Required 6.Install Watertight Risers and Covers to Within 6"of Finished Grade
/ { Sidewall=2(12'40"+2592'=151 SF Over Septic Tank Inlet,Compartment Wall,and Outlet D-Box,
{ Bottom Area=(12'-10"x 25) g=320 SF and One Leaching Chamber.
Finish Grade
Total Provided=471 SF 7.Septic System to be Installed in Accordance With 310 CMR I5)-.00& 1
/ I / 3 Max.
l 249 CAR 1.00,-7.00 Latest Revisidn and the Town ofBarnstalble
a 9 Min
' ---L4 .•--- / Compacted Fill
/ / LEACHING CHAMBER DESIGN Board of Health Regulations. Filter
All Pipes to be Schedule 40. Use 8.All Piping to be Sch.40 PVC. And or
_ J - --9.D-Box Shall Have a Minimum Inside Dimension of 12 and a i Minimum _ _ ....� r-< r--- -- �, � t::2"
2-500 Gal.Leaching Chambers m a - `
/ f 12'-10"x 25"Double Washed Stone Field as Shown. Sump of 6". 3 Pea Stone
10.The Separation Distance Between the Septic Tank Inlets and A 3/4" - 1 112"
Outlets Shall be No Less than the Liquid Depth.Inlet Tees Shall]Extend LEACHING
E CHI NG Double Washed
/ ( a Minimum of 10"Below the Flow Line.Outlet Tees Shall Ext--nd 14" CHAMBER Stone
Below the Flow Line,and Shall be Equipped With a Gas Baf11e;. 4' 10"
I I.Septic Tank Shall be a 1,500 Gallon,with 2 Compartments.
{ e^ Top of MAG NAIL W-- The First Compartment Shall Have a Volume of Not Less Than f
Gallons and the Second ofNot Less than 335 Gallons.
no CROSS SECTION OF CHAMBER
The Compartments Shall be Interconnected by a Minimum 41101
Vented Inverted U-Shaped Pipe with a Gas Battle on the Outlert.
-22.
NOT TO SCALE
_
1 •
M; 153
Existing PERC TEST: 15,198
J 1 Sty Metal PERFORMED BY.JOHN O'DEA,P.E.
" SULLIVANENGINEERlNG&CONSULTING
\ Maintenance Building A ' See Note 6 (typ.)
Slab On Grade EI=22.4' SOH,EVALUATOR NO.2911 F.G. EL.. 24.5
WITNESSED BY.DAVID STANTON,R.S.-TOWN OF BARNS TABLE F.G. EL. 25.0
r A. t NOVEMBER 8,2016
/ �r PASSED
Flow Equilizers
SITEProposed Invert f As Required
EL. 22.75 1500 Gallon
To BE CONFIRMED EL. 2 Compartment
!� Septic Tank EL. 22.25 EL. Top EL. 22.25
l \ f / TEST HOLE- 1 EL.15.0 TEST HOLE-2 EL.25.0 SEE NOTE 10
D-Box EL. 21.58
.0/ALAYER IAYR.4/2.... ...0/A.LAYBR 10YR 412 EL.'27.25 Leaching
�- --,?�� { DARK GRAYISHBROWN.'.'.'..'.' .'.'.'DARKGRAYfSHBROWN To Be Installed On f Chamber
.........
•
. 6 ... .. a e Compacted Base
SANDYLOAM............ ...... ,.SANDYLOAM...... .... 5
24.2 6 24.5
13 LAYER,I0YR.4/6.'.','.
B'LAYER 10YR.4/6 In�eectt n"P r ;1f`:.nc r'.`.:.;?
p o Port, cnte.arf faemcl?n & t2bplrlce'.;
DARK.YELLOWISHBROWN DARK.YFLLOWISH.BROWN & Baffels aii,tinsuitatsie Sorts sV�;h1n . nf..:'.
.._ _.1 ...... ... .. ...... ..... ...... ... N
26" LbA1bfYSAND....... ..... 22.8 30" .......'... L.OAMYS.4ND.'.'.'.'.'.'.'..'.'." 22.5 as Per Title 5 alie`Outsf;Pstim.et'ar. taha'..arYstem vi
Paved. Drive �41 YEL OWISHBR05/WN YELLOWISHBR05/ ::;:i 4
r
No Groundwater
/ MED SAND MED SAND/ 28" PERC TEST 22.7
Per Test Hole 2DEVELOPED PROFILE OF SYSTEM
-- 25 GALLONS GONE IN 5 MIN
�~ 42■ PERC RATE<2 MIN/IN(LIAR=0.74) 21.5 401, 21.7 NOT TO SCALE
.. z. ........... • /
_. � C2 LAYER 2 SY 6/3 C2 LAYER 2.SY 6/3
LIGHT YELLOWISH BROWN LIGHT YELLOWISH BROWN
~'`•T 126" MED.SAND 114.5 132" MED.SAND 14.0
Rough \, ' NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED
�PVSN OF Mq
SS..
i
JOHN
P .48166
"a n ire/
' G/STEF
"n�Fs OVAL���� .�;/'•/
�"�}-,.•�-^reµ
Notes/Revision: PREPARED FOR: PREPARED BY.- Title:
Proposed Rest Station Septic
1:) The property line Information shown was Wianno ClubC,apeSury
compiled from available record information. Engineering& r
suillVall Consulting, At Wianno Club Golf Course
o
2.) The topographic information was obtained g'Inc 7 Parker Road Osterville MA 01655 Off West Stre from an on the ground survey performed on (��� - PaBw659 • 7Par t)ke Rwd, atwMlle,MA0205 et 1�
or between 02/DEC/13 and 03/DEC/13. sw10s 111var Wn•com - ww wllivaneWrn.com (508) 420-3994 / 420-3995fax
Bamstable (Osterville)3.) The datum used is NGVD 29, a fixed mean 20 0 10 20 40 80 Field: WHK/RRL/MJD Review: RLH
Mass. Q)
sea level datum. Q)
Comp.: RLH/CTR Job Name: Wianno Maintance Date: Scale: rr r
Draft: CTR/RLH Drooling #:C515_13g1 ex1
December 13, 2016 1 =20
I
- M/AP 117
X15.10 \ 7, �
# 1i�o # 100
MAP 117 MAP 717
MAP 117 1 4R • ,, w ,i. * .'�
k
- - � � r - #1 # 1�7 #112�3 # 105 .R .•'. p; `.,.� �,:, it t.; '... ;� k*,*, .q`
_.., S
' � �_•_, MAP 117MAP 117
$ b,, ur ♦, T '1:
}
' O
i
p r
a>
1
>>
I ✓ \ 0 r .ia�`
• O
Location Map:
EXIIST6NG c>
T STATION MAP 11s
Iz� ASSESSORS REF..
1 Map 115, Parcels 022
t X15.25 i North
OVERLAY DISTRICT:
i
' \ \ Bay AP Aquifer Protection District
� I
;f
To 20o ZONE:
RF-1
EXISTING vLp
Pro//^^��oseal Overview Sketch Area
HOLDING TANK` `� F'
f (min.) 87,120 SF
TO BE j Frontage min 20'
� � � 1 200 g .( ) .
ABANDONEDJOR
-10 ' Width (min) 125
1 /12 REMOVECS ,,
Setbacks:
f OVIDE -
}' Existinq_� R
TH-2 � � Front 30'
- LEANOUT I
TH 1 G 1 sty Iw/f !_ ...... Side 15'
t t
I Rest Stctlort
I * ench lMark I X18.49
Rear 15'
e L SEPTIC NOTES
I b El �T / I DESIGN DATA
N slab , 1.Location of Utilities Shown on This Plan Are Approx.At(Least 72 Hours
Q it Pumping Records<300 Gallons Per Year Prior to Any Excavation For This Project the Contractor Slhall Make
300 Gallons/90 Days=3.3 GPD the Required Notification to Dig Safe(1-888-344-7233).
_ FLOOD ZONE.
/ 3.3 GPD/0.05 Gallons per Use waterless -67 Users Per Da
p (waterless)- Y 2.The Contractor is Required to Secure Appropriate Permits From Town
Z i Agencies For Construction Defined by This Plan. Zone: X (Minimum Flood Hazard)
t Park Toilet:5 Gallons per Person 3. Wherever Sewer Lines Must Cross Water Supply Lines Both Lines Shall p Community Panel No.
f _ I 67 People x 5 Gallons per Person=335 GPD
Q t f P P Be Constructed of Class 150 Pressure Pipe and Shall be Wlater Tested to #25 D 001 0757 J
ROPOSED Assure Watertightness. In General Water Lines Shall be Constructed in
Box Too w - July 16, 2014
_ y
0 BP ELF X I \ Septic Tank Coordination With COMM Water,and Shall be in Accordance
0 T
PROPOSED _ �9 / 335 GPD x 3 Commercial =1,005 Gallons With 248 CAM 1.00-7.00&310 CMR 15.00.
�0 `�•. �, tip ' (Commercial) „
S.A.S. Use a 1,500 Gallon-2 Compartment Tank 4.A Minimum of 9 of Cover is Required for All Components.
5.All Structures Buried Three Feet or More or Subject PROPOSED , J Finish Grade
TANK t Traffic t e H-20 Loading.It is the Engineer's
SEPTIC TA o Vehicular raffi o b g :.._.
LEACHING AREA :,f r r; = = L
Recommendation thatH2OAlways be Used. 3 Max. _�.€ IT,
LEACHING � ...
_ / I 335 GPD/0.74(LIAR)=452 SF Required 9 Min
f.,,.
��•-.� � 6.Install Watertight Risers and Covers to Within 6"ofFinislied Grade Compacted Fill Filter
..: Sidewall=2(12'--10"+25)2'=151 SF
Over Septic Tank Inlet,Compartment Wall,and Outlet,D-Box, Fabric
- J Bottom Area=(12'-10"x25')=320 SF And Or
and One Leaching Chamber. „2 » � »
Total Provided=471 SF 2 118 - 112
_ ....._
7.Septic System to be Installed in Accordance With 310 C11dR 15.00&
� -��---...%' 248 CMR 1.00-7.00 Latest Revision and the Town ofBamstable Pea Stone
_:__ 3'
! -_ _..._._. _...._. __.. LEA CHAMBER DESIGN s/4" 1 1�2"
, . -.. LEACHING `Board of Health Re Regulations.
_Sul!, ,J LEACHING ' Double washed
All Pi be Schedule 40. Use �
-� P�;b 8.All Piping to be Sch.40 PVC. � Stone
.. __ . . . . CHAMBER
L h in a .<
2-500 Ga Leaching Cambers - hall Have a Minimum Inside Dimension of 12 aind a Minimum
g 9.D Box S a
12'-1 "x iS Double Washed Stone Field as Shown.` ,�
0 Sump of 6.
T Inlets 4 10" -
-..-- .....-...- ._._,. ,..__ � 10.The Separation Distance Between the Septic Tank ets ar>nd
�' 12-70
. .. . - Outlets Shall be No Less than the Liquid Depth.Inlet Tees Shall Extend ,, I
t „
a Minimum of 10 Below the Flow Line.Outlet Tees Sha11!Extend 14
Below the Flow Line,and Shall be Equipped With a Gas Btaffle.
E9 PPe
. p R E
11.Septc Tank Shall be a 1,500 Gallon,with 2 Compartments. �
CROSS SECTION OF CHAMBER
The First Compartment Shall Have a Volume of Not Less Than
670 Gallons and the Second of Not Less than 335 Gallons. NOT TO SCALE
The Compartments Shall be Interconnected by a Minimum 4"O
Vented Inverted U-Shaped Pipe with a Gas Baffle on the Outlet.
PER TEST. 15,501
C S
PERFORMED BY.JOHN O DEA,P.E.
LIVANENGMEERING&CONSULTING
SULLIVAN
i
� SOIL EVALUATOR N0.2911
WITNESSED BY:DONALDDESMARIAS,R.S.-TOWNOFBARNSTABLE Provide
OCTOBER26,2017 Clean Out See Note 6 (typ.)
F.G. EL. 16.5
SITE PASSED F.G. EL. 15
Flow Equalizers
Proposed Invert r As Required
- TE T H LE-2 EL. 14.50 1560 Gallon
TEST HOLE 1 El.ls.o S O EL. 1s.s
TO BE CONFIRMED EL. 13.75 2 Compartment
... .. .. .......... ... .. EL 13.50
Top EL. 13.00
LOAM..... LOAM.' ..
Septic Tank EL. 1
.. D-Box EL. 12.33
g .... ... _.... .... 14.3 12" .. ......... .... ..... 14.5
SEE NOTE 10
.BLAYER.i0YR.5L4.......... BLAYER.l0YR.5L4:......... EL 12.00 Leaching
..... ........ ...............
-- YELLOWiSHk1ROWN..:...... YELLOWISHBROWN:........ ; To Be Installed On f, Chamber
e Bot. L. 10. 0
24"
>.QAMYSAND ... 13.0 26 G.QA1�fYSAND 13.3 Stable Compacted ase .
Cl LAYERIOYR 6/6 Cl LAYERIOYR 6/6 Bedding,»T"s
..
L.. Encourttere R Inspection Port, d erridve & Replace.::
BROWNISH YELLOW BROWNISH YELLOW & Baffels All Llnstitab{e So13:.4Vrtt)in.5
COARSE SAND COARSE SAND
as Per Title 5 TFae Qraten:P.erirfrEter of The Sysf' LO
• 36" PERC TEST 12.5
- ...
Plan Vier
25 GALLONS GONE IN 7 MIN.30 SEC. EL. 4.8
No 1»=20' " 10.7 501, PERC RATE<2MIN/IN(LTAR=0.74) 11.3 Per Test Holee2
52
C2 LAYER 10YR 6/8 C2 LAYER IOYR 6/8 DEVELOPED PROFILE OF SYSTEM
BROWNISH YELLOW BROWNISH YELLOW
120" MBD.SAND 5.0 128" AMD.SAND 4.8 NOT TO SCALE
NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED
*FOR PROPERTY LINE INFORMATION SEE*
LCP 14421 A,'K, & L
p��N Or M� V
JOHN
c � g
48163
s
GISTEF �°,•
sIOPJAL
Notes Revision: PREPARED FOR: PREPARED BY. Title:
Proposed Rest Station Se tic
: p p
1.) The topographic information was obtained Wian ')O Club 0
Enpp��neerinII &from GIS. a` g
At Wianno Club. Golf Course
Sul,11vall . Consulting,Inc. 0
(506)428.3344 • P.O.Bma 659 7 Parker Road,Ostervllle,.MA 02655 Off Ba.; Street
2.) The datum used approx. is NAVD 88. J
secl®sullNanen�ln.com • wwacsulllvaltenQln.com
_ Bamstable (Osterville) Mass.
20 0 10 20 40 80 Draft: JOD 7
Review: JOD Date: Scale: rr r
November 17 2017
1 =20
Project: 97039