HomeMy WebLinkAboutWEST BARNSTABLE DEER CLUB - FOOD WEST
BARNSTABLE-DEER CLUI
180 Id Sta a Rd. k
ode-�_l
ATM F Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BARNSTABLE, 2 F.P.(Thomas)Lee,.
MAS& Daniel Luczkow,M.D. Alt.
200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
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 S and 127A, a permit is hereby granted to:
Permit No: 172 Issue Date: 01/01/2022
DBA: WEST BARNSTABLE DEER CLUB, INC.
OWNER: WEST BARNSTABLE DEER CLUB, INC.
Location of Establishment: 1800 OLD STAGE ROAD W. BARNSTABLE„ MA 02668
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IncloorSeating: 80 OutdoorSeating: 0 Total Seating: 80
FEES
FOOD SERVICE ESTABLISHMENT: $100.00 YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE- ICE CREAM: G A
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:
• 1
For Office Us fl-l"
Town of Barnstable Initials.
L�
Inspectional Services 17�
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
NAME OF FOOD ESTABLISHMENT: (��s% �/st2NSi J6_4?C C-i-V,�5 -C/V C ,
ADDRESS OF FOOD ESTABLISHMENT: / 0'0 OG1) We-S�-_J4,z,J j P44%144_1
/4,9- 0 a 6 6 e �(
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 0� -,Oe s�a',L J 111V=j4' 01 �t— /rl D'�66�°"l
r - - f �V
E-MAIL ADDRESS: f �T� �����C/j�
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (J ��) �6�- A
TOTAL NUMBER OF BATHROOMS: 3
WELL WATER:YES)rNO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL:_� SEASONAL: DATES OF OPERATION:_/_! TO
NUMBER OF SEATS: INSIDE: go OUTSIDE:�TOTAL: 93 _
SEAMG: 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)?
TYPE OF ESTABLISWAENT: (PLEASE CHECK ALL THAT APPLY BELOW)
OOD SERVICE
TAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFASTGc %� �
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:\Application Foims\FOODAPP 2020.doc
OWNER INFORMATION•
FULL NAME OF APPLICANT
SOLE OWNER: YES,o D.O.B f2--23 Sy OWNER PHONE# 6 0 3f ! OYo �X
ADDRESS ,,i 7 �ae G C.e,-�1-er�/o (I.� -�4 O A 6 3 L `
CORPORATE OWNER: �G S� N.Sr'� ��62 cl,
�� Qf" .�9✓t,�CORPORATE ADDRESS: _/ �f�,�-G� �t.�., (���u� f �.,�,� � �- o�L� �
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 Allergen Awareness Expiration Date
2.
021- /)e/tL/4ot-,o/j
SI ATURE OF PLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openine!! Please call Health Div.at 508-8624644 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 Ert :JhywW InwnutbarnsUbir-asthg* iVWRWatrttlleatiuns 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.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC I st.
Q:\Application FoffnAFOODAPP REV3-2019.doc
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
DARNSTAUM Paul J.Canniff,D.M.D.
MAM 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: 172 Issue Date: 01/01/2021
DBA: WEST BARNSTABLE DEER CLUB, INC.
OWNER: WEST BARNSTABLE DEER CLUB, INC.
Location of Establishment: 1800 OLD STAGE ROAD W. BARNSTABLE„ MA 02668
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 80 OutdoorSeating: 0 Total Seating: 80 j
FEES
FOOD SERVICE ESTABLISHMENT: $100.00 YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q/
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
For Office Use
Town of Barnstable Only: Initials:
L
Amt Pd$
BARNSI'ABLE, : Inspectional Services
MASS.,
prEo �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
DATE Z�''�- NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: V" r�" ekr
ADDRESS OF FOOD ESTABLISHMENT: j0
®'� B S Cs� R®-90 Gv�S ►� �y3e.WI4 c� �/Y✓-�- L`xf.6�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: a9
r
TOTAL NUMBER OF BATHROOMS: 2
WELL WATER: YES- NO ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO
NUMBER OF SEATS: INSIDE: 9"::' OUTSIDE: TOTAL: `
SEATING: MUST OBTAIN A COMMON VICTU LLER'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 WAITS TAFF SERVICE DOOR(S).
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
QAApplication FormsTOODAPP 2020.doc
I ,
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: YE /N f D.O.B �'2-a3-�` OWNER PHONE #
ADDRESS—,! 7 �Q41jb P—A�j L�N� �a��,'A I
CORPORATE OWNER: V �S� %ZNIc- ���' U�� Jy�
CORPORATE ADDRESS: b o� ``0
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 Allergen Awareness Expiration Date
2. �� � -�°^� ri �Y i ay �
SI ATU 4APPLICANT 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://www.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 I st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
xtky Town of Barnstable BOARD OF HEALTH
�Y Paul J Canniff,D.M.D.
+ ' Board of Health Donald A.Gaudagnoli,M.D.
t BAtNSTABM John T.Norman
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: 172 Issue Date: 12/20/18
DBA: WEST BARNSTABLE DEER CLUB, INC.
OWNER: WEST BARNSTABLE DEER CLUB, INC.
Location of Establishment: 1800 OLD STAGE ROAD W. BARNSTABLE, MA 02668
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 80 OutdoorSeating: 0 Total Seating: 80
FEES T
FOOD SERVICE ESTABLISHMENT: $100.00 YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: ---- -- - - - —
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
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:
�TME toy, Only. Initials:
04 Town of Barnstable
Date Paid
9BAMMBLE, Inspectional Services
MA89.
i6.1go. eO
° Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
UAPPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE `mil NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: Pej 7—�S �— 4 -�-� C/4 I ly C,
ADDRESS OF FOOD ESTABLISHMENT: /Foc�- oC-Q s � �" � ` �`5r ov,69
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �-�J� �0 O�—�Sr 0 aCO 6�
E-MAIL ADDRESS: 1�4'0 e-. I/` deer G`e'�® "T—
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (v )09)
TOTAL NUMBER OF BATHROOMS: 13
WELL WATER: YES�NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: — FO OUTSIDE: TOTAL: 73
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)? Ylk G4j4---
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)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q\Application FormsT00DAPPREV2018.doc
rr Y
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: YES/tO D.O.B �-' �� OWNER PHONE#
ADDRESS
CORPORATE OWNER: Gam, FEDERAL ID NO. :
CORPORATE ADDRESS: do �'� /�a�0✓J I/`�e'� lY "J /1A-f— 0e2'�
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
12-1
2.
GN OF PLICANT 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://www.townofbarnstable.us/healthdivision/applications.asy.
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
Employee Signature Forma
NOTICE: Permits run annually from January 1st to Dec.3l't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
Q\Application Forms\F00DAPPREV2018.doc
Bellaire, Dianna " ` Oub
I
From: McKenzie, Marybeth
Sent: Wednesday, December 05, 2018 8:25 AM
To: Bellaire, Dianna
Subject: RE:W B deer Club
Morning, I guess they don't need a well test for the water because they are limited in use and number of people using
the facility. I informed them if anything changes then they will have to get it tested.They currently do not have any food
on the premise and are not cooking. I have them sending in their CFM and allergen certificates.Thanks Mb
From: Bellaire, Dianna
Sent: Tuesday, December 04, 2018 4:15 PM
To: McKenzie, Marybeth
Subject: RE: W B deer Club
Okay.
Dianna Bellaire
Permit Technician
Town of Barnstable
Health Division
200 Main Street
Hyannis, MA 02601
P:508-862-4643
Fax:508-790-6304
Email:Dianna.Bellaire@town.barnstable.ma.us
From: McKenzie, Marybeth
Sent: Tuesday, December 04, 2018 4:12 PM
To: Bellaire, Dianna
Subject: W B deer Club
Hello,
Please hold W B Deer Club permit because they need to post their CFM, allergen, and test the well water.Thanks Mb
1
� I
HEALTH INSPECTOR'S Establishment Name: i Abate: -
oF�HE roe, TOWN OF BARNSTABLEW Page: of J_
OFFICE HOURS y i
AR E., PUBLIC
2 0 MAIN STREET
-DIVISION t3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
3: 0 :30 P.M.
.A.F �0� HYANNIS,MA 02601 sos-sz FRI'46" No Reference R-Red Item PLEASE PRINT CLEARLY
"rEOM�" F OD ESTABLISHMENT INSPE TI N REPORT qor
Name Date e o 1 s ec'on
O tSe'r-v
Routine ULM
Address isk ' ooi Re-ins ionevel e1; Previous pw
Telephone Residential Kitchen Date: ada
Mobile Pre-ope io r
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
�
0
Inspector : Other��Jjo 7bjL, 1=1n Is . I I
Each violation checked requires An explanation on the narrative p ge(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)
❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 11.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 n
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 66�1�`k'•S
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations /d
Critical(C)violations marked must be corrected immediately. (blue&red items) J 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 Voluntary Disposal checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ g y ❑ rY p ❑ 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 4 non- rib violationscal violations
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-criti =B. Seriously Critical Violation=F is scored automatically if: no hot
C=2 critical violations and less than 9 non,
If If 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
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 non-crit' al violations. If 1 critical refrigeration.
29.Special Requirements (590.009) y P
within 10 days of receipt of this order. violation,4 to 8 non-critical violat' s=
30.Other DATE OF RE-INSPECTION: Insp ct r' nature Q
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N Yfl
#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
9
Dumpster Screen? Y N all-
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* L 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. 3-302.14 Protection tion from Unapproved Additives
* 19
2-103.11 Person-in-Chazge Duties PHF Hot and Cold Holding
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*
7-102.11 Common Name-Working Containers*2 590.003(C) Responsibility of the Person-in-Charge to
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
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 * 11 3-501.19 Time as a Public Health Control* -
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use p _ 590.004 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) Variance Requirements
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 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*
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 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 I 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
Equipment
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 Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective rurzoor
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) F Ratites,Injected Meats-155' 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*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
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* 3-401.11 2-301.14 When to Wash* 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 Requirements.
radicsrho ld be debited under#29-Special
$ 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 23-30)
3-202.15 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* Ln 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
* 5-204.11 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 l 29, Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 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.
pp THE Tpk, TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: Date: Page: of
q OFFICE HOURS .`
s An.N Eoi PUBLIC
MAN STREEETSION• 3: - :30A.M.
:30-4:30 P.M.
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS, MA 02601 M -FRI. No Reference R-Red Item PL SE PRINT CLEARLY
soa-8-asz-asaa
'POMP' FOOD ESTABLISHMENT INSPECTION REPORT
4
Name ate Tvne of T o s c ion
p "Routine
Address Risk ood Sery ction
Level ai revious Inspection 4 Of
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector IIA) Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
r
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
�e V
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals K
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hrdousoods) ,ter
❑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 -s
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control AN
❑ 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 Violatio !on
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. linspect
L� O ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Basen today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMk 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) cited in this report may result in suspension or-revocation of the food B=One critical violation and,less than 4 non-critical violations 9
if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
2 Water,Plumbing and Waste (FC- 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)(590.006))(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,-7 to'8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address
y
29.Special Requirements (590.009) s o within 10 days f receipt of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dump er 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 Signatu a 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 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-Chazge 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
Other*-- 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 - - 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 Separationg-Storage
Applicants* 3-302.11(A) Food Protection* 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 Requirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions*
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 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 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 Warewashing-Hot Water 7.206.12 Rodent Bait Stations
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 Warewashiug-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
Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec*
- 5-101.11 Drinking Water from an Approved System* 81=
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eb ripe 1na001
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
Approved 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
- Shellfish and Fish From an ro ed Source gg pp 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 Recreatiouall Caught MolluscanEquipment* ---
Y g Contact Surfaces of
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 - D m cater-
- 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 WOd 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* * 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.
5 Recelving/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 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*
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* 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
3-202.18 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(0 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. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 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.
TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: Date: LPage: of
r OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
RARNS7'ARLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MAC, �. MON.-FRI.
�A ,639,pie HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY.
M FOOD ESTABLISHMENT INSPECTION REPORT
Name «. at ( T e o e o s io
Routine
Address Risk ice Food Sery - - ec Ion
Level Previous Inspection
Telephone " Residential Kitchen Date: -
Mobile Pre-operation
Owner (C_` HACCP YIN Temporary Suspect Illness I ��
Caterer General Complaint
Person in a(PIC) Time Bed&Breakfast HACCP
(�
E, In: Other �f
Inspector Out. -
' J 1
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. 01
(Vi j
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) ❑ Qh 7A <
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/Knowled eable/Duties / &W
❑ 9 9 ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS I.
❑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 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
❑ 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 El Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating ry P ❑ ❑ P ❑
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 ❑ 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 4 non-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 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 C=2 critical violations and less than.9 non-critical. If no critical water,sewage back-up,
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 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) PY
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
Permit Posted 7 Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's S, tur Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted -Y N (�
Dumpster Screen N
Po��r �
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* F 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.* . 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* 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 7-201.11 *
Separation-Storage* 3-501.16(A) Roasts Held At or Above 130°F*
Applicants* 3-302.11(A) Food Protection* P g 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)3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* Variance Requirements
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 Reted of Food* Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS
590.003(E) Removal of Exclusions and Restrictions��] Disposition of Adulterated or or Contaminated 7-204.12 Chemicals for 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 Wazewashing-Hot Water 7.206.12 Roden[Bait Stations *
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
Y 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
Equipment
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 Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff QR9e iniaooi
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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec*
Sources* 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 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )�)
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements.
radicsshould 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°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23-30)
3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F 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
3-202.18 Shellstock Identification* 13 Handwashing Facilities 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 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* 130. 1 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.
Health Master Detail Page 1 of 1
Logged In As: TOW nialkusk Health Master Detail Wednesday,August 30 2017
Application Center Parcel Lookup Selection Items
Parcel Septic Perc Well Fuel Tank
Parcel: 152-003-001 Location: 1800 OLD STAGE ROAD,West Barnstable Owner: WEST BARNSTABLE DEER CLUB INC
Septic 1,3/23/1995 New Septic...
Permit number: 1995058 � Permit type: Select type Complete system: ❑
Issue date : �3/23/1995 - Complete date
Septic tank size: Type/Size of SAS: j
Installer: Select Installer Card on file: ❑
w
I/A service type: jLeiect service 1-77 Innovative/Alternative Technology type: ISelect IA type v
Variance date : �---i Abandon complete date aff Abandon permit number:
Repair deadline date : Repair notification date : F Ear, Keyword: j
Comments: Delete Septic
New Inspection...
Number - _Inspection Date Inspector^�^�___....___�-�����_ -..._..__�...._.._.____.. Result
Iv M=jSelect Inspector Select result v
Received Date Comments
8/30/2017 0H
Save Septic Changes Return to Lookup
i�
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=l 52003001 8/30/2017
No. �`� t.
Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppricatiou _for Yell Cou.5tructiou Permit
Application is hereby made for a permit to Construct(✓, Alter( ), or Repair( ) an individual well at:
-Zo c -4 � z
15 ' 003 W l
Location-Address 'A"s�sessors Map and Parcel
Owner Address
Installer-Driller �— Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well �)01Gt�c Capacity 0 rPtivr
Purpose of Well
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certi ate of Compliance has been issued by the Board of Health.
Signed OND WELL LY '..LING, INC. I i
5 RAYBER ROA' )X 2783 Date
ORLEANS,M "!2653
Application Approved By (508)240-1000 J 7 v
Date
Application Disapproved for the following reasons:
Date
Permit No.,/-) v�-wl ®� Issued
Date
BOARD OF HEALTH
TOWN OF BARNSTAB ®E oNDV3
!� !� LL DRUING, INC.
Certificate of Compliauce 5 RAYBER ROAD,BOX 2783
ORLEANS,MA 02653
� (508)240-1000
THI IS TO CERTIFY,that the individual well Con�sttructed" Altered( ), or Repaired( )
by 3 4J L.L-1/V
Installer
at �'�aZ> C�T 12-c�i� LZ)�i 5 z
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well,Protection
Regulation as described in the application for Well Construction Permit No.�/( "Qvh—L Dated � ��L, �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
O�L
No. (J���� Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYication _for Yell Construction Permit
Application is hereby made for a permit to Construct(�), Alter( ), or Repair( an individual well at:
`b0� Ala S�- <)e-14, \N--&L, 15Z( 003 1 W
Location-Address Assessors Map and Parcel
l�Q( C lug C? -`�AzN 5 22 OZC6K
Owner Address n
Slmcty�c�, yV�l� � (Ay f\9 A)J�,1 �-y �D�l c�� OCUAnS IVV1 02(,;3
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well \26-6k Capacity �-ej P�-n
V1
i
Purpose of Well 90�4u—
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certi Cate of Compliance has been issued by the Board of Health.
Signed -4� �, I
�jDate
Application Approved By (�_ / �) /�
Date
Application Disapproved for the following reasons: '
Date
Permit No.JA d �P Issued 1,0
` Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed(�� Altered( ), or Repaired( )
by S'n GUI L 9 JG L,l
Installer
at ll'�D O j W tZ IZ C�64 t�' C�e��
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well/Protection
Regulation as described in the application for Well Construction Permit No. i/(p- Gb-- ) Dated I
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date. : .. Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
'� / VeYY Con5tructton PermitNo. ''`�c��f9 �' G � � Fee
Permission is hereby granted to > d�� ( tiLL:L,�)f2 (4-L-1,V to
, � Installer
to Construct k" Alter( ), or Repair( ) an individual well at:
No. AC30D 0�,
Street
as shown on the application for a Well Construction Permit No. c � 4 r--�._ _ Dated ( p
Date -( ' I/ (A Approved By
......................................
J
X�l
41
100 Fee
153023 153014,
N 184. N 220 —
91881 t53p O
N 1881 N 188
Q► 152015
152033002 N 227
N1135
1620360Ot "!
1502036002
No6
152003001
+� N 180p
162035003 � 04
N 8 162036 dD0d p�1825 qr
152018 152003008
N 398' N 1285
152038
N 1784. ` 152003009
N:1301 162007
152N0 786110 �152W40b1 � 162004003 N630}
VSQ F e
h N 1770 N 1740
1✓152004002
t62039 �r1 V 764 152006 162008�
NOW Massachusetts Department of Environmental Protection
Bureau of Resource Protection
-DD 3—l.27` f
Well Completion Reportstk
."
Well Driller `
Please specify work performed: Address at well location:
.. ................... _....._......
New Well Street Number: Street Name:
1800 OLD STAGE RD
Please specify well type: Building Lot#: Assessor's Map#: '
'Domestic 001 152 m
Assessor's Lot#: ZIP Code: {�
Number Of Wells: 003 02668
Citylrown:Well Location BARNSTABLE W I,'o
In public right-of-way: GPS
(7 Yes f`No ' North: West:
41.68990 70.37699
Subdivision/Property/Description:
Mailing Address:
click here if same as well location- address
._............e.............._.._........................._..._........-...........-.............._.................._.i
Property Owner: Street Number: Street Name:
WEST BARNSTABLE DEER CLUB 522 PO BOX
City/Town: State:
Engineering Firm: BARNSTABLE MASSACHUSETTS
ZIP Code:
02668
Board of health permit obtained:
f ..Yes t`Not Required
Permit Number: Date Issued:
W2016 021 09/14/2016
r
Massachusetts Department of Environmental Protection
Bureau of Resource Protection-Well Driller Program
• Well Completion Reports(General)
Well Driller - General Well Form
DRILLING METHOD
;.Overburden Bedrock
uger Choose Bedrock--
-WELL LOG OVERBURDEN LITHOLOGY _
From(ft) To(ft) Code Color Comment Drop in drill Extra fast or slow Loss or addition
stem drill rate of fluid
i
0 11 (20 Sil Sand Brown Fast Slow
YES NO __ Loss Addition
__i
20................._ �2bmmxrr" .Silty Sand E► Brown �'Fast t Slow i
YES NO . I Loss Addition
[Silty
y
5 45 Sil Sand [Brown +� l" E{ Fast r'Slow
YES NO Loss Addition
Silty Sand ► (Brown f Fast t �Slow
Lt...................._..._..._...........___...... L_.__.�_.._.._....................._.::::.... YES NO Loss Addition
_....._.............................................. ................................_...
........._.................._.................._....._._.._............._.................................._.........._....__.....
..
...................... ._
65 75 Silt Sand , Brown ±�i ES 1 r Fast Slow Loss Addition
75 90 Fine To Coarse S �Brown � Fast4 .SIow
�____-_�__ ' lVv_.-__.. _ LYELNO [Loss Addition
90 100 Sand And Gravel �; Brown r Fast r.Slow
YES NO .......... Loss Addition
WELL LOG BEDROCK LITHOLOGY
�Loss i
Drop in Extra fast or I or Visible Rust I Extra
From(ft) To(ft) Code Comment I addition of Large
drill stem slow drill rate ;fluid Staining Chips
Chi
.....----....... ........ ........
L Choose Code ) . ( � �'--Yes I'�'Yesil
----- -- . YES NO Fast Slow I I Loss Addition J
...........__..........................................._.........................__......................................._..................._...... ."J._.:..._:....:::::.:...................__::c-.....__..::..........::r..:.:.:::.............._{.'....................................:::.....::::::r............................................................................................_
ADDITIONAL WELL INFORMATION
Developed 'Yes f No Disinfected Yes i No
Total Well Depth 100 Depth to Bedrock
Surface Seal Type None racture Enhancement Yes No
CASING rY7 Is Casing above ground From 1 Ta 0
From(( To Type Thickness Diameter Driveshoe......................................................................... ........................._................. ........._.....
0 96 Polyvinyl Chloride j Schedule 40 • 4 �:Yes
SCREEN `I.No Screen
From ;To Type Slot Size Diameter
..._.........._............................_........... .. ._.............................................. __—__........._...................................................._.... -._..._...._......_.._........._._.........._..............................................................
...:_._
96 ; 100 Stainless Steel Well Point 0.012
WATER-BEARING ZONES ff DRY WELL
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Well Driller Program
yam,
Well Completion Reports(General)
t
From To Yield(gpm) j
43 100 12
PERMANENT PUMP(IF AVAILABLE)
.............-.................................._.....................................
2 Wire Constant Speed
Pump Description i Horsepower
Submersible 3/
Pump Intake Depth(ft) 80 Nominal Pump Capacity(gpm) 10
ANNULAR SEAL/FILTER PACK
' Water Batches Method Of
From To Material 1 I Weight Material 2 j Weight
- I (gal) (count). Placement
—� Choose Material i, Choose Material
WELL TEST DATA
Time Pumped Pumping Level(ft Time To Recover Recovery(ft
Date Method I Yield(gpm) (HH:MM) BGS) (HH:MM) BGS)
09/22/2016 ;Constant Rate Pump f 12 ! 1 30�j 44 0:01 43
WATER LEVEL
Date Static Depth BGS(ft) Flowing Rate(gpm)
Measured
09/22/20116 143
COMMENTS
WELL DRILLERS STATEMENT
This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete
and accurate_to the best of my knowledge.
DESMOND
Supervising Driller
SEAN Monitoring[M] III,
Signature
DrillerMORGAN Registration# 764 THOMAS,E -
DESMOND WELL
Firm DRILLING INC. Rig Permit# 023 Date Job Complete 09/ 9:/2016
NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion.
September 24, 2018
As per Inspectors and Sharon Crocker, a food service rate was negotiated because they are not using
kitchen very much.The kitchen is only used for banquets or an occasional wedding. We will still collect
SS/AA cert' ' tes.
Dianna Be laire
Permit Technician