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2504 MAIN ST./RTE 6A(BARN.) - Health (2)
2504 MAIN STREET, BARNSTABLE LAMB & LION INN '� ° o t u c E a 4 { t i i i i I a �- � ., r, o n � •k c Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / Lt1 2504 Main Street, Back System € Property Address tQ Lamb &Lion, Inc. ry Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 . required for every page. Cityrrown State Zip Code Date of Inspection !' Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information ,Sly 1�f3(o$ filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. Box 89 Co _ ffi Company Address it Forestdale MA 02644 Cityrrown State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training-and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails February 5 2020 Inspe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. Ckyrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y , ND)for the following statements. If"not determined_," please explain. The septic tank is metal and over 20 years old" r the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfil ation or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection i it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le than 20 years old is available. ❑ Y ❑ N ❑ ND ( plain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or br k out or high static water level in the distribution box due to broken or obstructed pipe(s) or d e to a broken, settled or uneven distribution box. System will pass inspection if(with approval o oard of Health): ❑ broken pipe(s) are repl ced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remov d ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is veled or replaced ❑.Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the B and of Health: ❑ Conditions exist which require furthe evaluation by the Board of Health in order to determine if the system is failing to protect publi health, safety or the environment. a. System will pass unless Bo rd of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2504 Main Street, Back System Property Address Lamb&Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning i manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil sorption system (SAS) and the SAS is within 100 feet of a surface water supply or trib 1 ary to a surface water supply. ❑ The system has a septic tank and S S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and AS and the SAS is'within 50 feet of a private water supply well. ❑ The system has a septic tank a d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**. Method used to determine distan e: **This system passes if the well ater analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates abse t and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow , ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is wit 1 200 feet of a tributary to a surface drinking water supply El El Area system is I ated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA or a mapped Zone II of a public water supply well t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street, Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Z ❑ Existing information. For example, a plan at the Board of Health. El Determined in the field (if any of the failure criteria related to Part C is at issue ® approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 r example: 110 gpd x#of bedrooms): Description: Number of current reside s: Does residence have a arbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include I undry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 y ars usage (gpd)): Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M � 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Bed and Breakfast Type of Establishment: 1175 Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 10 Bedrooms Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No 2018=677 GPD 2019=633 GPD Water meter readings, if available: Current Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Ready Rooter records: Pumped Oct. 2019 Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street, Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: . System installed 06/07/2011 Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan):. 5 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owners Name information is Barnstable MA 02630 January 28, 2020 required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 4.2 Depth below grade: feet Material of construction: ®concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 16.5'x7.5'x7.5 4000 gallons Dimensions: 1 Sludge depth: 501. Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 22" Dip tube and tape measure How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4000 gallon 2 compartment tank. Inlet and outlet tees in place. Liquid level at outlet inverts. Risers bring all covers within 6"of grade Recommend maintenance pumping every two years. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts �. Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 2504 Main Street, Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete [] metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum t top of outlet tee or baffle Distance from bottom of um to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal /E01 erglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street, Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is required for every Barnstable MA 02630 January 28, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and oat switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, 6 outlets w/speed levelers in place. No solids carryover. H-20 DB-9 is 5' below grade with riser and cover 6" below grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r , Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb&Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of p mp chamber, condition of pumps and appurtenances, etc.): *'If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: 2 sets of 6 w/ ® leaching chambers number: - stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.R28/2018 Tide 5 Official Inspection Forth:subsurface Sewage Disposal system-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2504 Main Street, Back System Property Address Lamb 8t Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to locate and inspect units. 1+" of liquid in units at time of inspection. Light staining 1.5' below invert. Clean stone visible in side walls. No sign of past hydraulic failure. Both sets of units are vented. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer, Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater nflow ❑ Yes ❑ No Comments(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 18 r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ¢� 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of Lofhydraulficilure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 • a Commonwealth of Massachusetts IfTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,V 2504 Main Street, Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA 02630 January 28, 2020 required for every Zip Code Date of Inspection page. Cityrrown State D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I 3 � - vim I ` o � ' O > + s® . t$insp.doc•rev.MAW 8 Title 50fficial Inspection Form:subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owners Name information is Barnstable MA 02630 January 28, 2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells >5 Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 03/28/2011 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: maps massgis state ma us/oliver.ph You must describe how you established the high ground water elevation: Test hole in 2011 found no ground water at 216" (elv=28). Base of SAS at elv= 39.2 per engineered plans. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts , ,p Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2504 Main Street Back System Property Address Lamb& Lion, Inc. Owner Owner's Name information is Barnstable MA _ 02630 January 28, 2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist, Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: P 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE � ¢ n LOCATION #A-kyk-t i�! ��" SEWAGE# _.�U 11 — 15-3 VILLAGE t (,r-_4_ffe t_P ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) ((.TjC,�_ �JLj NO.OF BEDROOMS C i�E-� e-V_J OWNER {mot��bk�^tZ PERMIT DATE: COMPLIANCE— 1( COMPLIANCE DATE: Separation Distance Between the: e Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility l( F-f— Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) i Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) t4.10,: Feet FURNISHED BYvw �Pr Grlsiv�r�..n Q �4 r � � ♦ o.� �{ o0 c O 0 ti A"-No. 2�t' S3 -`�,1.. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS fiplitation for disposal *pstem Co=stem Permit , Application for a Permit to Construct( ) Repair(�'Upgrade( ) Abandon( ) ❑Individual Components Location Address or Lot No.cAs-oq A4odn,%., -jaxcCN% Owner's Name,Address,and Tel.No.;&_®? 36�2_&so3 z4m6 f G.vn�inj 1.4 a oo. 13K 5-// Assessor's Map/Parcel . S rn 0cA4 jp Installer's Name,Address,and Tel.No. .go�-S138 Ft`ia(a Designer's Name,Address,and Tel.No. S20T �crraAu oar% Type of Building: Dwelling No.of Bedrooms !O Lot Size 94 �sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) //00 gpd Design flow provided f®�f gpd � Plan Date & awl Number of sheets Revision Date Title I l p c'S- �i�e Plat) Lam/ c2n Off,/ Awk-1-4 f n S P _ Size of Septic Tank 410 /P�p Type of S.A.S. � -I/g�14.": /-a-SUOqj�d04 Description of Soil es" Q � C .5011 r i Nature of Repairs or Alterations(Answer when applicable) 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 Enviro ntal Co and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Sig Date l �� Application Approved by Date 1 Application Disapproved by Date for the following reasons Permit No. 9-0 11 -t-5 3 Date Issued // t Apt,No. UII ' rs�� �. FeeTHE COMMONWEALTH OF MASSACHUSETTSEntered in j/ PUBLIC HEALTH DIVISION.- TOWN OF BA►RNSTABLE, MASSACHUSETTS Yes W - W ., 121"PYitation for.,,isposal *pstem Construe '04'- tit `Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) omplete System ❑Individual Components Location Address or Lot No.aS-CU y' Ma In$}. sy�5 t Owner's Name,Address,and Tel.No. G s LGL/=r�¢j•tG,on�r� C_GP /?o. gi/ Assessors Map/Parcel -S {3yC S p u G Installer's Name,Address,and Tel.No. �o 8-VP$- �5a(�, Designer's Name,Address,and Tel.No. S'vg � /.xsr-fola{�i, 114 _ s :a 4p .4z D Type of Building / - Dwelling No.of Bedrooms ��� Lot Size �}/�f7 'sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers.( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �f U� gpd Design flow provided // gpd Plan Date AN ;9 O)/ Number of sheets Revision Date Title ;s ) �erp S �/ 7 _ Size of S eptic,Tank ul� T �' -�1�TYPe of S A.S. - Sc f Description of Soil -Sp. ) is i Nature of Repairs or Altera!tions(Answ 1j11er,when'applicable) , Date last inspected: Agreement: t t ) The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage gp2sal system in accordance with the provisions of Title 5 of'the Enviroonnmen�Co a and not to place the;system in operation until a Certificate of Compliance has been issued by this Board of He tfi. Sig Date (I Application Approved by t f , , e .i I (i i 6 �,;ff Date / Application Disapproved by Date for the following reasons. Permit No. _ 2 o i► -/IL 2 Date Issued / -------------------------------- 0 I�HE COMMONWEALTH OF MASSACHUSETTS 5T" -ao W'y``- -BARNSTABLE,MASSACHUSETTS (Certifirate of Compiiarrce THIS IS TO CERTIFY,that the /On-site Sewage Disposal system Constructed( ) Repaired(40- Upgraded( ) Abandoned( )by I4r fs�ln%7 W. (eO(•IBC ✓ ® / C: at UCHi( , i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 J _ dated Installer ; -- �. t�C Designer <�n t .. — �r ',,..�OT��.n�"C', r a #bedrooms�/ Approved design flow !///p gpd The issuance of this permit shall not be construed as a guarantee that the sy/s rfi'win1 c n a designed. Date�/1,111 Insplrctor -� No. 2-U 1 1— � Fee UU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS -- . - �IS�IOsaY �p�tellt �oU�tCULtIDU �errillt Permission is hereby granted to Construct( ) RepairLl/1 Upgrade( ) Abandon( ) System located at ,?S() �;, 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 years of the date of this permit. Date S /c, /i Approved by kv. �� Town of Barustable I RE Department of Regulatory Services BAR rAH Public Health &VJlSiol<ll Date MAM 200 Main Street,Hyanuis MA 02601 t6yq. ti� Date Scheduled— ` Tine . 00 Fee Pd. Soil Sid tability A,ssessnz ent for S'ewag'q uposaIl ep Perfonned By; Witnessed By: n 4 -LOCATION a.°r. 0E IRLA1L l!1i1F-OR1VMTION Location Address a S o IG V-+ /� Owner's Name �C, / �LI a� 67e�p (I � Address 'J! !J Assessor's Map/Parcel: 0'6`7/ Engineer's Namc Q t.JvL 1..GY C NEW CONSTRUCTION REPAIR Telephone It C�O� �36.2 lvvv Land Use- XeL4 iG=o slopes(To) Surface Stones Di Distance's from: Open Water Body Ft Possible Wet Area fl Drinking Water Well ft Drainage Way It Property Line . ft Other ft SKETCH, (Street name,dimensions of lot,exact locations of lest holes&pert tests,locate wetlunds in proxinuty to hales) 41 50�ilk,✓ Parent material(geo)'ogic) 0 Depth Lp Re[Iroelt `T�!d Depth to Groundwater.:Standing Water in Hole:—' �eb/b�t Weeping Imil)Pit pf1cp 7�U 3 Estimated Seasonal High Gioundwater AI ♦ +� D]CTERIMNATION FOR SEASONAL HIGH WATER TABLE x, Method Used: - Depeh Observed standing in obs.hole: A In, Depth io w1l lilutd..ec Dcplh to weeping;from side of obs.hole: e l!:, Oruundwular.Adf uslrnent e I't. Index Well R Rcading Date: Index Well level AdI.ftletoi'_ A41,Orpululwater UVel . PERCOLATION TEST Observation q Holt f1 T'tnle nt 9" ' _�CjSt��02 L- Depth of Perc �1f Tlmp at G' �-� Stott Pre-soak Time @• � _ � Time(9"-6'7 End Pre-soak 1 Rate Min./Inch �A4 h Site Suitability Assessment: Site Passed Sit.G-Failed: Additional Testing Needed(Y1111) Original: Public Health Division Observation hole Data To Be Completed on Back----------- ***If percolation test is to be conducted witllin 100' of wetland, you must first Uotify the. Barnstable Conservlltlorl I)1Ylsloll alt least one (1) Weel6 prior to beginuing. Q:\S CPT[C\PLRCFORM.DOC 1 D E1E)P-OBS)ERV 7[Ip�T H®�,�+.LOG ---- Depth from Soil Horizon Soil Texture Hole# �— Surface(in.) Sail Color Soil• Other (USDA). (Munsell) Mottling (Stntcture,Stones;Boulders. Con istracy.%' ravel NC 54; iay��tio�l Depth from DR EP 013SERVATION HOLE'LOG LOG ,ry Soil Horizon 110le �w Surface(in.) oil Texture Soil Color Soil (USDA) Other (Munsell) Mottling (Structure,Stones, Boulders. x7 f; Conslatenc %Grave) (��►,�- --� 3 G�192 C SL slr&A.45 le; YA DEEP OBSERVATION IT®LE Depth from g'®G Soil-Horizon # Surface(in., Soil Texture Soil Color. Soil (USDA) (Munsell) MottlingOther (Structure,Stones,Boulders. Co_nalstencv.%n yell . ----------- DEEP 013S]ERVAlTION HOLE LOG Depth from Soil Texture Soil Horizon HD�a?# — Surface(in.) Soil Color 5'0ll Other (USDA) (Munsell) Mottlin g (Structure,Stones; Boulders, COnsi2tengy,%aravrtl Flood Insurance]fate Maw t^; Abovc 500 year flood boundary No Yes K. Within 500 year boundary No Within 100 year Hood boundary No Yes -i Depth of Natu>rallY Occur! : Pervious Material Does at least four feet of naturally occurring pervious materlal exist in all areas observed thl•oughout the area proposed for the soil absorption system'? If not, what is the depth of naturally occurring pervious matorial� 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 training, expertise and experience described in �10 CMR 15.017. - Signature .n �� i Date . . t Q:1SBI'TICIPERCFORM.DOC ' q Ci Fee ° No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes p PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS A"Ov pplication for ;Dtgpo9;a1 *pgtem Con5truttion Permit Application for a Permit to Construct( )Repair(t/ )Upgrade( )Abandon( ) 1p/complete System ❑Individual Components Location Address or Lot No. �©q y—� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ` / ��� ✓ Install 's Name,Address,and Tel.No. Designer's Name,Address and Tel.No- �drt��� Type of Building: r� Dwelling No.of Bedrooms ` Lot Size sq. ft. garbage Grinder(Z-fo Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ,�!/� Design Flow `f� gallons per day. Calculated daily flow `/ z 65) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank�.��'D 4P1' Type of S.A.S. Pd Q Description of Soil Nature of Repairs or Alterations(Answer when applicable) , I 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 syst--m in operation until a Certifi- cate of Compliance has been issued by th' Bo d Heal . Signed Dater Application Approved by Date 'Z1' Application Disapproved for the following reasons Permit No. l3 Date Issued "` Z 3 —T 7 .. a. ' . - , '~ M1tY•e p.f.. . ,. _.. rK iJa,,M•. . -.^t1 ..f Z� - .. No. / �/ I 1 Fee THE COMMONWEA..LI"OF MASSACHUSETTS Entered in comp4itr: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETT97- - �,��a 01ppfication for Mi_4pozal *p.5tem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ). L complete System ❑Individual Components - �y Location Address or Lot No. ro Y Owner's/Name,Address and Tel.No. Assessor's Map/Parcel 7 / (, _ /,re/�G ✓ Installe 's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,��l�O LD�/ CO�isT -7�~��� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( � Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow, M9 gallons per day. Calculated daily flow �Z gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /��O 90 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable�,�'���`/C gg- I 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 Certifi- cate of Compliance has been issued by th' Bo d Hea / c Signed Date Application Approved by _ Date �'Z.3'9 9 Application Disapproved for the following reasons r Permit No. 1`� ' Z 3 Date Issued' ---------------------- THE COMMONWEALTH OF MASSACHUSETTS F^ BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER IFY,that he On-site Sewage Disposal System Constructed( )Repaired( �;)Upgraded( ) Abandoned( )by— A O!7`Z� at ,4' O ST4 has teen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z dated Z 1. Installer Designer Ae, lJ The issuance of this permit shall n,toeco/,stFued as a guarantee that the systm w 11'function as designed �/� /Date � Inspector . J�f �!. t �d I/ 'I W. / t No.—��� Z��-------------------Z_JF7 --Fee ��•�� THE.COMMONWEALTH.OFMASSACHUSETTSK PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5po5ar *pztem Construction Permit 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 recognizes his/her duty to comply with Title 5 and the following local provisions or special-conditions. Provided:Construction must be com leted within three years of the date of this p it. Date: ��� 3 - Approved by - ` a 1/6/" .. NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) v L bel-r T �D�r� i , hereby certify that the application for disposal}works construction permit signed by me dated y/���� ,concerning^the e T property located at Zf� C�14%�t�7`> 6 /ys �/meets all of the following criteria: /The failed system i connected cyst s to a residential dwelling only. There are no commercial or business es associated with the dwelling. e soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system e V There are no private wells within 150 feet of the proposed septic system v' There is no increase in flow and/or change in use proposed v There are no variances requested or needed „ /The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the'groundwater table using the Frimptoi /method when applicable] Y If the S.A.S.will be located with 250 feet of.any vegetated wetlands, the bottom+of the proposed o- leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, . N Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment Z `7 Z Z �l DIFFERENCE BETWEEN A and B ' r SIGNED : DATE: c / (Sketch proposed plan of system on back]. q:health folder:cert r 1 (� Af" y GUI !-7 PCPA �:Ilx�, (JSQS: -L.�6'eila /'' TOWN OF BARNSTABLE q o' LOCATION � fa SEWAGE #104 V_H LAGE AOIA5 127i/e ASSESSOR'S MAP.&L LOT ZS7—Qp� INSTALLER'S NAME&c PHQNE NO. `o `. Lo A4: SEPTIC TANK-CAPACITY I-Ar LEACHING FACILITY: (type) —<_C0 `R\ bftAft 2CS (size) di 3S 7 `r> NO.OF BEDROOMS BUILDER 0 OWNER PERMTTDATE: COMPLIANCE DATE: 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 O O Ar x TOWN OF BARNSTAIIPEd S� LOCATI01 _ �/� SEWAGE# VILLAGE , AQII 5, /271 e- ASSESSOR'S MAP & LOT INSTALLER'S NAME&-PHQNE NO, SEPTIC TANK CAPACITY ISoa CTAr LEACHING FACILITY: (type)' S S�4k,--C"16eCS (size) Io�'x 3S a'D NO.OF BEDROOMS BUILDER O OWNER 1 e/' PERMPTDATE: COMPLIANCE DATE: 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 Iii 31- ag, 4 - 35 3 . JUN-09-2011 09:52 From:BORTOLOTTI CONST 508,12893139 To:15087906304 P.2/2 TOWN OF BARNST'ABLE LOCAMON . W FN SEWAGE 4 r It VI.LLAGE S'1UgarL-���LASSESSOR'S MAP&PARCEL,�=AbtZ7-� INSTALLER'S NAME&PHONE NO, � �..l• S U� '7`71����� SEPTIC TANK CAPACITY ��•� ��{-L �EE I LEACHING P'AMITY:(type)=rgT _ A4 i.l-�"t /.�1.(size) ' k It.;rA,a& NO.OF BEDROOMS_.,. tin - OWNER t PPRMIT DATE: �r� I f COMPLIANCE DATE:. SePMrMtign Distance BetW¢C11 the: ,y Maxinipm A40stcd Groundwater]'able to the Bottom Of Leaching Facility J 1 r� Foet Private Water Supply Well and Leaching Fueility(If any wells exist on sim or within 200 feet of leaching facility) Feet Edge of Wettand and Leaching Facility(If nny wetlands exist within 9U)feet of leaching facility) Feet rUP,NISHED BY j Aq 4 - r - c � I 6 �O y.��b" y. ro+• Or 04 or nip W-p( rn nv j mnjeatrCJa^�iai"u1��ramirlawfuimu)3-0 • ��:1 �"1�11 '� :�.Itil'4r IAI�_ T. 11.L4) 'S! 1.0.:!1 �(°'fE'fl j,e4 . ,r h'� 'tL?X�''131�_L�� Alm :1II`ahC r�'Alum dvdUtk1w, ��"S°�➢'�' la dLut;;, E::rarIStHM((�,�_. (.+dT,CT��Jlq fir�u-'t�ria) LA980'uN �" �i, "IIIV (,,LtL�t�tl 16 Nrl�jUlGrOY) 1r-1*�IIV1l() • '1'i9 t11i�5'IhJ7 11k1[�� ;,uw;L,�[S�Lta�)�'[ti37J'� 'fit'_q � Y#;tm �sitt�aa,u�a�U'►and,(rltra�' .. ��i,.ti aq�,}u Twot1,ean ,Cup 'u VS:q�n u(allsrc�jai' o T). R Yank 0fhyrz Tim P;)FI'EJ�. 77.�1'M �nuc)v �rwt4ua,rwi�;�a r1ti�;riC: �r,�J:�s �rr� 1uc[; 1t�r¢�7,'r L •�tr� 7�i�aG,To �7rtti;Xr� tY01'1t1.t�rtlr;tF1 ay;�o nc?rlxraulo t rqi)VrL, sn tpr C'- R'ttri panu.�JJu �u.'riln ;*Lrnpa1 K©:u 4.VIM `ttadwop �# ALti7 a�tia:a�z=�ilta�ltz sgt R?[Lt��tiu� e�xy onr,c[r a;r�l�,t� �: rrolr„s )q. n Wa 4IrLp, x4wj j . (aaLL r�a17ir5 �l ` '( tl Pm) fie[ LntL:�Tp 1 e�:rg>�uu.paG�te�: L4 FYI tsIoIS :,x#t $ ,� f f y r Oft"Ntl'. ksd. - tvv '(.9R"AOS' '�'�w 1I4#�T.�aJAA!`a�lc�tu�ttt�;g'dan,(0 �t►taiu�Map4 .. - •`, .it�lsyx�i�a=1�'��i� 'y1I 1sSAA1u1'�� "'gyp �. ` ") f Id W Gj::01; tLlae 60 'Unr ,ON. xI�A au; 6u1.LQQui6uy Qdpm wrap: WQ�J 2/T'cd i7�906Z8091:01 662682b90S 1SN03 IllO7M:M:w0Jd 2S:60 TT02-60-Nnf 003 _-_ -- , op DATE: 10/27/95 . lN ST� 4 PROPERTY ADDRESS: 250_ Route 6A RECEIVED West` Barnstable ,Mass . ----------- ----------- oz66a � NOV 3 1995 . - HEALTH DEFT. TOWN OF BARNSTABLE s On the above date, 1 inspected the septic system at the above address. This system consists of the following: 1 . 1-2000 gallon septic tank 2. 1 -Distribution box. 3 . 2-68x8 ' block cesspools . , 4. 2-1000 gallon leaching pits . . Based on my inspection, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code) 2. The distribution box cover should be raised. 3 . The septic tank shoul'd 'be; pumped. 4. The septic system is in .proper working order at the present time. SIGNATURE- Name: JostEh P._Macomber_ Jr.-- Company:_J_P•Macomber & Sonf Inc: Address: Box 66 ------------------ grv_ille1Mass .,02632 Phone:___So8=77�_333^8 THIS CERTIFICATION DOES NOT CONSTItOTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools- eachfields Pumped & Installed Town Sower Connections P.O. Box 66 Centerville, MA 02632-0066 .775-3, 38 775-6412 s 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs RWDepartment of Environmental Protection William F.weld • Goamor Trudy Coxe • S*ctsluy,ECEA David B. Struhs Commissionst SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION roperty Address: 'g.5-041 120dT Z,4 "67- I�AkJV5544 Address of Owner: ate of Inspection: 16rA5— (If different) ame of Inspector: -T&SepJ7 rwadervfee. 74 omn�t an Name, Address and Telephone Number: -T/.�� �co�m he f f ox ERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate nd complete as of the time of inspection. The inspection.was performed based on my training and experience in the proper function and aintenance of on-site s wage disposal systems. The system: r . Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatu_ Date: The System Inspector shall submit a copy-of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. . Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: A/0 One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection: Indicate yes, no, or not determined (Y, N, or ND): Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or.exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. , (revised 6/15/95) 1 .-__.__ a:..... 6...•�F1� n��na w FAY(6171 5S&1049 • Telephone 617 292-5500 v::iY:`:: i}, � U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ar�d K��r-e, an we-3 77 !✓,�/C'l1o's r4IF 4/ 4w$$� Owner: .?CRA)#Js Rr�R— Date of Inspection: /0•- -C,46— B] SYSTEM CONDITIONALLY PASSES (continued) u Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 1] The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet,of a surface water 140 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system ndS d set)Uc IdIlk d11j buli dbburptiun system and h v,4h1r. 100 fee, to a surfacc v.ater supply c,ii:uuta j tc a surface water supply. j l The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. Jy� The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 4, D] SYSTEM FAILS: NX) I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: g5ioLl RQu7'E f A Ltksr 6r�RA167-)4 U,� Owner: UeAT4V&- i'!0 < Date of Inspection: DJ SYSTEM FAILS (continued): Y Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 limes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ►no-Al RlMV WAY lYlwo-. jW Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ►j Any portion of a cesspool or privy.'is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (large System) and the system is a significant threat to public health and safety and the environment because one or more,of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within.200 feet of a.tributary to a surface drinking water supply 1 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well; The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I" (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: o2i'D� /rOG%r �tj We ►21��1 ,�a�ve 1lcrce Owner. , Date of Inspection: 1p z 3 -9s' Check if the following have been done: _V/pumping information was requested of the owner, occupant, and Board of Health. - None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 2s built plans have been obtained and examined. Note if they are not available with N/A. _.4/The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow */he site was inspected for signs of breakout. V All system components, eluding the Soil Absorption System, have been located on the site. Zhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. the size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility ov.ne: land occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. n 14IneAld'97' 3 Se, Ng'm bdITON (revised 6115195) 4 �- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72-' 1 r /ZAR►IPiv-a, kk mKG Owner: 'Tca lva Cce Date of Inspection: a FLOW CONDITIONS RESIDENTIAL: , Design flow: gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no)--I- Laundry connected to system (yes or no): ' Seasonal use (yes or no): ' Water meter readings, if available: I ' � Last date of occupancy: `�' r�J✓ ' COMMERCIAUINDUSTRIAL• / Type of establishment: Design flow: ,gallons/day Grease trap present: (yes or no)AZIP Industrial Waste Holding Tank present: (yes or no)AL-9 n-sanitary waste discharged to the Title 5 system: (yes or no),V ,ater meter readings, if available: !V" -- Last date of occupancy: '�11 OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS a d sour e of information:, r e System pumpecKas pan of inspection:.(yes or no)L!Q/ -. If yes, volume pumped. -gallons Reason for pumping: e TYPE OF SYSTEM _Septic tank/distribution box/soil absorption system / Single cesspool �_ Overflow cesspool �/ _ Privy 0 Shared system (yes or no) (if yes, attach•previous inspection records, if any) (� Other(explain) APPROXIMATE GE of components, date date installed (if known) and source of information: 156yrw,,�5 ' .� o�,— J''i y'S I � ye•¢R$ 0� �?a�YyI�CCr�.be� rt u�'�w�. cage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S PART C. SYSTEM INFORMATION (continued) • Property Address:45-0y 64/ _ 6j*,,/ S7_ �i9�N3TAy,l�! ri?.�53; Owner: �Qi4N/Ye' Q1e.6 Date of Inspection: SEPTIC TANK:2RMp'ljf�44,15 (locate on site plan) Depth below grade: Material of construction: Zncrete —metal FRP other(explain) Dimensions: IrKVJ 'G WI e Sludge depth:19 Distance from top of sludge to bottom of outlet tee or baffle:XE Scum thickness: y'/ Distance from top of scum to top of outlet tee or baffle: a c� . « Distance from bottom of scum to bottom of outlet tee or baffle: /Z Comments: (recommendation for pumping, condition of inlet and outlet tees pr baffles, depth of liquid level in relation t4 outlet invert, structural integrity, evidence of leakage, etc.) , A tS + oL/ T fiZ %S GREASE TRAP:49' (locate on site plan) Depth below grade: Material of construction: —concrete —metal _FRP other(explain) AAA Dimensions 41, Scum thickness: . Distance from top of scum to top of outlet tee.or baffle:, Distance from bottom nt crum in bottom or outlet tee or baffle:, LIL Comments: , (recommendation for pumping, condition/of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _ AAA)P-j or.r (revised 8/15/95), t' 6 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C pp � >>�� SYSTEM INFORMATION (continued) l60 Property Address: �T u7t-' �E� Lj( ST 414eV S7-r? Owner: , JO'14N qa RtZf' Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: allons/day Alarm level: , Comments: (condition of inlet tee, condition of alarm and float switches, etc.),. DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: ' Comments: (note if level and distribut-vi. :, equa; e�idence of solids carryover, evidence of leakage into or out of box, etc.) , e' r' .Q PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)—&A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) An9� (revised 8/15/95) 7 UY . SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: T_ C(ftP T �+R►�fUg7�A� L j'�-4S'5-,. Owner: r9NC Date of Inspection: !B— ,y--�� • E • SOIL ABSORPTION SYSTEM(SAS):, , (locate on site plan, if possible; excavation not required, butte iay be approximated by non-intrusive'methods) If not determined to be present, explain: Type: leaching pits, number: a� leaching chambers, number:n leaching galleries, number:, leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: 1 Comments: (note condition of soil,.signs of hydr ulic failure,'level of ponding, co dition of vegetation,etc.) CESSPOOLS: ' (locate on site plan) Number and configuration:- Depth-top p(liquid to inlet invert: Depth of solids layer: — - - Depth of scum layer. Dimensions of cesspool: ` Materials of construction: Indication of groundwater: 61 _ inflow (cesspool must be pumped as part of inspection) Com : (note condition of sell, signs of hydraulic failure, level of ponding, condition of vegetation,'etc.) aim S �4 e , , .4 PRIVY: (locate on site plan) Materials of construction: ft� ��, Dimensions: Depth of solids:_ Comments: (note condition of soil, signs of hydraulic failure,,level of ponding, condition of vegetation, etc.) Al/llti�. (revised 6115/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (,te nn� re l SYSTEM INFORMATION (continued) o roperty Address: d-4/ 1ou r ub-'a I' � �11 /` fk,&e-; wner. '9,ae ate of Inspection: /V—a 0_9f f;_ e SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks-or,benchmarks locate all wells within 100' !ur.,u ur�� L'S.C' • VZ) 1 . C- �L\ DEPTH TO GROUNDWATER Depth to groundwat method of determination or approximation: 4AI 6 A fhe 07ern oqe L (revised 6/15/95) 9 y>•nrne-r rn.•r•r—.�Y,rnrm'•nrstrrrrc.n-rrs*.r.::•srr,rvr�+ TOWN OF Ra rn S to hl P - BOARD OF 11EALT1.1 ISUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION h F•••rt• -T••.-•.:,--. r.^.--e•..r.-n•n:rrirs.-rr.rx,r-rn-r:�+-u:srneanr+ar-rrarw-e:*es"a rsmrs-rmr•trri:v�m+rr•n-•.-nrrr•r.-tee•-,.A -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 2Sni R „+o �e West Barnstable,Mass , ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Jo8nT11 Ri �P .� PA1?1' D CERTIFICATION T NAME OF INSPECTOR Joseph P. : Macomber Jr.. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville,-Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE �508 ) 7 g�¢� � �R�� FAX ( �nR pan 15R7 rra r err s s� ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspectionr The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems`-. Check one : - XX X .X Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* - :c• The inspection which I h;Ave conducted has found that the system failzs' to Protect the public Health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector • i nature ll )� Date S g One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection- FAILED, th'e owner or operator shall upgrade • the avatem.<.. within one year of the date of the inspection, unless allowed or requi're�.; ,. otherwise as provided in 310 `CMR 1.5 . 305 . j* V) THE COMMONWEALTH. OF MASSACHUSETTS a DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph .P... Macomber, Jr. Has satisfidd the-Department's qualifications as .required and `is hereby authorized to u se .the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the p p • General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control � • Water Coris'ervation SAYE ; Tips ME! • .r.`CHECK FOH. LEAKS Water Loss in'.Gallons Due to Leaks Leak this Loss Per Day . ,Loss Per Month ' Size • .120 3.600 • 300 10,800 • '693' 20,790 • 1,200 . 30.000 ' •• 1,920 57;600 t 4y296 .128,960 • ® •: 6.640 199,200, 0.9.84' '• 20Q,520 6,424 . 252 720 • ' , 8,888•'' ",296,640 11,324 339,720 12.720 .381,600 1.4,952 448,560 V / Date: G TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: S t ', A- MAILINGADDRESS: O IOVt�,,oV�S VIi(` ��C Mail To: Board of Health TELEPHONE NUMBER: Town of Barnstable CONTACTPERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUM AR: Hyannis, MA 02601 TYPEOFBUSINESS: tt Does your firm store anv of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils 71; Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including ch"oroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I- - .. - Dater - ii ' TOXIC-AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: S Mc,�`o MAILING ADDRESS: T•r/ .?-)r,-x -Z�S 1AA Mail To: -- �TELEPHONE NUMBER: Board of Health ? -�?a�}� Town of Barnstable 1 ! CONTACT PERSON: II jj P.O. Box 534 I' EMERGENCY CONTACT TL •PHONE NUMB R: If( Hyannis, MA 02601 ,A <<. TYPEOFBUSINESS: L , I' Does your firm store any of the toxic or hazardous materials listed below, Either for sale or for you own I use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed G envelope for your convenience. t< ,. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: i ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS ' Thye Board of Health has determined that the following products exhibit toxic or hazardous character- istics andmust be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants f Engine and radiator flushes Road Salt (Halite) `f Hydraulic fluid (including-brake fluid) -Refrigerants iea r Motor oils La"56 71; Pesticides s. Y k NEW USED (insecticides. herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED r Other petroleum products: grease, Photochemicals (Developer) t lubricants, gear oil NEW USED Degreasers for engines and metal. Printing ink F Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine j Rustproofers Lye or'caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes I Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's - Lacquer thirener-s Oti7er=chioTinated hydrocarbons;`- NEW USED (inc. carbon.tetrachloride) ' Paint & varnish removers, deglossers Any other products with "poison" labels i Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids t (dry cleaners) r Other cleaning solvents i Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY,COPY�-BUSINESS, SeP. 17. 2013 11 :48AM h. 1951 P. 2 EN VIR 0 TECH LA B ORA TORIES,INC. M4 MU.NO..M-MA 063 8 Jan Sebastian Drive rich 12 Sandwich,AM 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Lamb$Lion LOCation Barnstable,MA Address ATTN:Alice PO 0ox#511 , Barnstable 02630 Sainplebale 09/11/13 Coflected By Client Sample 27ote NA Sample 7�pe Swimming water Date Received 09111113 Lab Order Number M130825 l X;gcglion. otrtee Dole.Colteeteif 77me Collected Crurbt�hGf I B 911112013_ Na spa A notysis Requesfed Vnils Recommended Lintifs Analysis Result Method DafeArralyzed Anatyzsd,8y Total Coliform /100 ml 0 0 92228 9/11/2013 MC ............ _ .... .__. Standard Plate Count /1 ml 200 MT 9215 B 9/11)2013 MC Pseudomonas Aeruginoso /100 ml 0 0 0213 E 911112013 MC Comments: Yes-Water is suitable for swimming for parameters tested. Date` DIM Snarl iGaboratory DPrecto BRL=BelowReportable Limits Page 1 of 1 $See Attached Lamb ana Lion Inn Aril 20th, 2010 Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Re: Qualified Swimmers Request Dear Board Members; The Lamb and Lion Inn is seeking a lifeguard modification for qualified swimmers to be used in our swimming pool. The Lamb and Lion is open year round with the use of the pool from June through September. We are located at 2504 Main Street, Barnstable. =' CJ The Owner/Manager of the property is Alice Pitcher. The Innkee°pier on situ is Alice Pitcher. I can be reached at 508-362-6823, with any questions and— concerns.' y i Sincerely, rn Alice Pitcher `�.S , �a �� 5� �.� �,� , . • W i� www.lambandlion.com E-mail: info®lambandlion.com .2504 Main Street(Route 6A) • P.O. Box 511 • Barnstable, MA 02630 (508) 362-6823 9 Fax: (508) 362-0227 APPLICATION FOR A PERMIT TO OPERATE A SWIMMING POOL Application is hereby made for a permit to operate a public or semi-public swimming pool. This pool is to be operated in accordance with 105 CMR 435.00: Minimum standards for swimming pools (State Sanitary Code: Chapter V)and the.Town of Barnstable Code. OWNER: \iC 2 �; c���r PHONE: POOL LOCATION ADDRESS: A S U 4 (o POOL TYPE: (circle one) INDOOR POOL OUTDOOR POOL SPECIAL PURPOSE (le. hot tub) SKETCH: Please attach a legible detailed sketch with dimensions, depths and detailed pool volume calculations SIZE: Swimming area (>5' deep) aSG sq.ft. Non-Swimming area(<or,=_5') sq.ft, MAXIMUM BATHER LOAD: Swimming area: 13 people. Non-Swimming area: _people Bather load calcs per 105 CMR 435.27: 15 sq.ft. of surface area per.person for non-swimming area 20 sq.ft. of surface area per person for swimming area 10 sq.ft. of surface area per person for special purpose pools POOL SUPERVISION: (circle) Lifeguard* Qualified Swimmer** *Attach certification copies **Applicant must file a separate request to the Board of Health with certification and insurance copies CERTIFIED POOL OPERATOR: (attach copy of CPO certificate) DISINFECTION (type of chemical, method, capacity, etc. ) FILTRATION (type, size, etc) 3� UU NUMBER.OF MAIN DRAIN(S): I If>1, drain cover centers at least 3' apart? ADDITIONAL SYSTEM\DE VICE FOR ANTI-ENTRAPMENT: & e- V pa ANSI\ASME Al 12.19.8 COMPLIANT DRAIN COVERS? (unblockable drains exempt if they are at least 18"X 23"or at least 29" diagonal measuremen ) SPECIAL NOTES: DATE: SIGNED. *NOTE: You must file a separate application for each swimming\special purpose pool. Q:\POOLS\Pool Application 2009.doc ' � .. �.. � ��� `_ .`�.�� '.,�• - ..�.�.�.�r. J ..� .-.. �. sue_. 11 . r .. . �� (S�) _ 1 � � � � > - e R� T' __ / t - �� �I �- i ' � �. .. � lv e e� c� _ f � . I� � ` o , _ • ( � 3 � 1 � sy4�� Z ' - ` . . � � .�.. / dD is X a X 7 � 6;p7z_ R. .�,�'�'x'.7: eti.`"�°f= :c •9ts•'. :•a':P •s�:�s' q:'s•. e\f va y.,``�/r �Tti:'r i�a�:si' 'S'*'Ft3."v .s'itii�,y°" �., � o ✓ '. rl.•.�'•♦ •Fi •t �•y j� y �oy�� t,y:A.A°�a. y�oo•:r,�ii• tt •V• .dli d. a°• .1'L"` P. .r°•ii'•• di��'i .� • t'i•`a°d.Y° �ir •'4yaL Y .:4e °° '1.•Q V�'••i'y•6.��•.�'•iy:�1°•.Ctyy �y. .�•. /I� ♦kIf no,• 0!i!G .� "1!�" ♦h b�.d'Yi`•�•*ta 40} ��'..w d�W�4�di+�at 6 �(Odf Yd°18w 4y f�4�O�r 0.di�0 dYy*d:.r�6d'1 id•' klS�•P e��d J,/� d0 P'}O al Md0��963Jf YI �'60d�`•'��4 Ir+.ae•40d Ys��•OOd v�� 4 b��O+d+Y° .°'4y�j� .•G I. .s'at. } ,, i!. } .f ., td.d' *r`0 ••�!4 4i , �'ti" oa� oar y!}4` t�,o-r ,�♦. 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T �• C.E.O. 4 lit,✓ a: •. ° ( a .. s: +' 4s'% d'- 4 1 ' 4 � ;r• 1 r f v 4 '� 4 '`' �,: � p t �' r,,,,� .. i i + >Y,F 1 ,.. :� { :: %. t; �: ;,44 � Nl., ,: f � � .k ., ,: # #'t, :; 1'• F, �: " i . { .� ; ��:' ,, � E•• ir�•..�� • .. , f¢d .,i+f r,t , y �b � 1��,,. � ,g e � .�l+��rr����� ;►ti¢ 4� , a nr� 1 4 .a !• rJ t, irk k !� Y +O F ' l�nt�� .t d !°! �j ¢'!! ��►�'�k/�: 3! ��� r « !� } e %!P �+ F! ��� v odi f . n •• m � e,k �d° � t,�4 + yr r t,a ✓ at lq f. 1� Ay ,i°� �o+: :y,.y<h,,;.,t°r::°4,♦ k O t `••t�t. �°yti�°;e. .. o�,. f.r A•4 a '+�:• '�"5• }. _� �f. °�. �'y -•u�P +�4t�.�.•° 4.. •!�4!�t°�!.yd�b°: ;.,48� O� ,Jb �``�2=✓•=,�,.;•�- ''R'':.F,:"4c_h'�t`,y'�='��.y���a.�= -'��'2• .'��,',�'�Z�',fF_... ;+�'•\'',�' ,.t'�; ,�Fis�,.;t9/• :.�+J�i�c 2 ��k ,�. �?.v' Owe•+•i�-� °CSC `� mar �y�•���.�.�%�':L�.�/� �/��"�,�„� s:r� �•a'4�1�\'z-- ��f '�.. \• �..rr*• �'�ri,�'�—,.(''\�ty`� ,i ��, %`.��, T=a �\�i"..: :'�. � /1 r/��.. +'� f APPLICATION FOR A PERMIT TO OPERATE A SWIMMING POOL -Application is hereby made fora permit to operate a public or serif public swimming pool. This pool is to be operated in accordance Kith 105 CwIR435bd: Minimwn standards for swimming pools(State Sanitary Code: Chapter\11 and' To m of.Barnstable.Cole. OWNER: co� PHONE. POOL LOCATION ADDRESS: v c _Q^ POOL TYPE.(circle one) h,LOOR POOL-- OUT7h70RmPC)OL PEC.G�l aURPt?SE(� g 't_tub SKETCH: Please attach a_eeible detailed;ketch tvih din p ns, uepths and detailed pool volume calculations SIZE: Swimming area (>S' deep)-- - sq.ft. 1,4on-Swirriniin�area or S'} sq.ft. R'l BATHER LOAD: Swimmins.area people. 1V'on-Sv►•imming area people Bather load-calcs per 105 CNIR 435,27 15 sq.ft.of surface a:ea per perscn for non-s-41Jrtisiing area 20 sq.ft. of surface'area.per person for swimming area 10 sq.ft. of surface area Per person for Speciaa aurpoSe.pools POOL SLTPERN'ISIPM.(circle) Lifeguard* Quali:ied SwirntnEr' *Attach certification copies **Applicartrii~st file a separate request to the Board efHealth v,,ifh certification and.insurrcP copies CERTIFIED POOL OPERATOR. _(attach copy of CPO certificate) DISINFECTION(type of chemicaLr method,capacity c tc rj a - FILTRATION(type,size, etc } - � NUMBER OF MAIN DR.ALN(S): (�If>l, yin'cover:.caters at least "'apL-t? ADDITIONAL SYSTEM\DEVICE FOR AI`TTI-ENTR41 MEINTT: ANSP.4SME A172.19.8 COMPI:IANT DRALN CO�'EIZS? _ _ (unblockable draans exempt if they.are at least.l3"X 23"or at least29"diago:ra! meas�..trernent} SPECIAL NOTES: DATE: '�-� 0 SIGNS *NOTE: You must file a separate application for each smvimminespt,'al purpose pool: QAPOOLS'Pool Application 2g49.doc I _ Succes�ful ry T„R A IFN hN G��,_u Instructor • ,� �T., t u "a Regist u be 1�5t 1 171M ti V • X Trainin ender Phone No: + Name a� � _ Expires Train ng Center ID Issued-A MEDIC FIRST AID-BasicPlus follows ILCOR,AHA and ASTM recommendations n certifies fhb ie ndry duoF6ramedabovelias sua�shily ai and guidelines for CPR,first aid and emergency care.Additional source authority Eemgnstr tedthe klo�ledgeandskillobjecti�r: informatiogcan be found in your Student Guide and at medicfirstaid com ; ttasi Plus CPR,AED-and,'First Aid forAd Its i` W Continued proficiency as a MEDIC FIRST.. requires frequent - 0{_ i t i' retraining.This card expires as documented on the front of the card or within D-Basic CPR and First Aid for Adults ; yy 5. f, ry1 24 months of issue. Card otvandif€noreKhanorie�bolx hec ed MEDIC' FtrLt pId ®2009 MEDIC FIRST AID International,Inc medidirstaid.com rt:. .... R TAR A I Nil NiG s x, Instructor Completion Ba s CPR GAR CardJ„;� , Regi Name .+ Trairte s I�hoahe" moo" ITeafnin Center.1D t r 'Issued-d ,�,.r�; Expires .. 9. acernfiesthar'thendronamedabovehossuccess(uIty MEDIC FIRST AID*BasicPlus follows ILCOR AHA and ASTM recommendations 41 a.y p , .e and g idelines for CPR,first aid;and emergency care.Additional source authortty �d mo d the,knowtedgeagdskAlobjectives lor. information can be found in your Student Guide and at medidirstaid com .tj Sit:PIUS CPR,AED,dnd Frst Ald for dults .'Continued proficiency as a MEDIC FIRST AID Provider_requires frequent ©ids[CPRfaid for Adretraining.This card expires asdocumented on the front of the card or wtthin 49 24 months of issuenot valid' reahan one box is chec ed MEDIC ' — � ®F first pid 02009:MEDIC FIRST AID International Inc. medlcfirstald com f MMONWEALTH OF MASSACHUSETTS • TOWN OF BARNSTABLE SW9XV1ING POOL INSPECTION REPORT TYPE OF POOL: PUBLIC ❑, SEMI-PUBLIC'❑ SPECIAL PURPOSE ❑ POOL VOLUME: GAL. MAX. BATHER LOAD NAME OF POOL I Q ADDRESS OWNER ADDRESS Regulation 105 CMR 435.000 effective date:2/20/98 The items marked below with an"X"indicate the violated provisions.Items marked with a check are satisfactory. °V 0 Bathhouse and sanitary facilities adequate lighting,ventilation:sanitary condition.Adequate enclosure around pool.Gate self-latching 4 ft.above ground. 04.Sewage disposal _ZO5 Location,structural stability,finish �/0'6 Water circulation&filtration systems.Filter effluent flow meter reading gpm.#of turnovers % 0066 uitable automatic equipment for disinfection of pool water. 06 CO2 equipment for pH control CO2 cylinders anchored Inaccessible to public Adequate ventilation. V08 Inlets&Outlets-Inlets located to produce uniform circulation.Over rim fill spout 6"above max.water level.Properly shielded&located. -1/_ 08 Main drain suction outlets covered w/suitable protective covers/grates.Cannot be removed w/o use of tools.Open area does not provide entrapment of fingers,toes, etc...At least one anti-vortex drain provided 08 Each system outlet protected against user entrapment by anti-vortex cover or by other means.Minimum of 2 suction outlets provided for each pump,properly located and plumbed. V 08 Suction outlet covers in place,unbroken and secure and cannot be removed except w/use of tools.Close pool immediately if outlet covers missing,broken,loose J/ or can be removed w/o tools until repairs are made. ! 14 08 Special purpose pool&wading pools equipped with emergency shut-off pump switch.Accessible and prominently marked. ✓09 Cross-connections.Potable water supplied through air gap. ✓10 Skimming Facilities.50%of recirculation drawn from surface of pool. J �12 Line with floats separates non-swimmer area from deeper water. V 12 Water depth markings on deck and walls.Properly spaced.Boundary line on pool floor and walls.Step edges marked with contrasting color. 13 Walkways&Decks 4 ft.wide.Safe condition. 14 Ladders,steps-one per 75 feet.Not less than 2 ladders. dill Diving equipment in safe condition. 17 Pool supervision provided.CPO w/proper training.On staff or on contract,Documentation provided. �r _ 21 Permit issued.Adequate maintenance and testing records.Records initialed by person making tests.441VEK 22 Health Regs.Signs posted Warning signs for special purpose pools. _ 23 Lifeguard ❑Qual.Swimmer ❑If lifeguard:proper credentials,proper suits and garments worn.Whistle&bullhorn provided.Qual.Swimmer:CPR trained, BOH approved.Limit bather load to 19 ❑Red or orange bathing suit with proper lettering for lifeguard ❑Yellow Qualified Swimmer attire �24 Safety Equipment.Ring buoys and rescue hook provided.Rescue tube and backboard w/straps at pools attended by lifeguard. _ 25 First aid equipment provided.First aid kit complete. +s//25 Emergency Communication system at the pool and in working order.Emergency communication device in unlocked area and available at all times to staff and the public.Operating instructions and emergency numbers posted. _ 26 Waste&backwash water disposal properly discharged.No direct connection to sewer system.Separation tank provided for diatomaceous earth filter backwash water. 29 Chemical Standards. Frequency of Testing: POOL SIDE READINGS IN PARTS PER MILLION-ppm Bromine 2.0-6.0 Total chlorine Alkalinity 60-150 Free chlorine 1.0-3.0 Cyanuric Acid 30-50,max 100 Comb.chlorine 0.0-0.2 Water temp. 78-84,spa<104 pH 7.2-7.8 z Z _ 30 Water testing equipment DPD kit provided for chlorine&bromine.Unbreakable thermometer for special purpose pools.No test strips 31 &32 Water Clarity:Can see 6"black disk at bottom of pool.Water clarity maintained.Filtration operating continuously. 4A32 Special purpose pool drained&cleaned every 14 days minimum - 33 Thermostatic control provided for each SPP.Thermostatic control only accessible to the pool operator. _ 34 POOL MUST BE CLOSED UNTIL IT MEETS 105 CMR 435.29 THROUGH 435.31.If the pool is closed by a Health Inspector or other agent of the B.O.H., the pool shall remain closed until the Health Inspector re-opens pool in writing. COMMENTS: r SIGNE • SIGNED: I DATE: OPE ATOR Board of Health/He lth De . Representative 05/10/2006 WED 15:01 FAX 508 888 6446 ENVIROTECH LABS Z 001/002 ENVIROCH LABORATORIES, INC. ? MA CERT- NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (.108)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Splash Pools,Orleans Loeation emb& :ion Inn Address Box 388 Barnstable MA So.Orleans MA 02682 Sample Date 05/01/06 Collected By J Wester Sample Time 9:15 Sample Type Pooi Date Received o5/ol/o6 Lab Order Numher DW-2006-1391 Well Specs NA Zocadon Source Dare Collected ., Time Collected ;Comrrre�:ts A-Pool 611106 9:15 Analysis Requested Units Recommender/Limits Analysis Result Method Dafe Analyzed Analyzed By _ Total Coliform(pool) 1100 ml 2 0 __ 9222 B 5/1/2006 RS Pseudomonas aeruginoss /100 ml 1 0 9213 E 5/12006 RS Pool-Standard Plate Count /1.0 ml 200 <1 9215 B 5/1/2006 RS Comments: ---. ._-- — - .-- YesL Water is suitable for,swimming forparemeters tested- ----— ... . Date �� Ronald J.S ri lahorata Di for BRL—Below Reportable LLnifs Page 1 of 1 *See Attached r e. Lamb ana Lion Inn July 31, 2006 Town of Barnstable Board of Health 200 Main Street ` Hyannis, MA 02601 Re: Qualified Swimmers Request Dear Board Members; The Lamb and Lion Inn is seeking a lifeguard modification for qualified swimmers.to be used in our swimming pool The Lamb and Lion is open year round with the use of the pool being from May until Octrober. We are located at 2504 Main Street, Barnstable, MA. The Owner/Manager of the property is Alice Pitcher. The Innkeeper on site is Alice Pitcher. I can be reached at 508-362-6823,with any question or concerns. S'ncerely, Alice Pitcher wwwlambandlion.com E-mail: info@lambandlion.com 2504 Main Street (Route 6A) • P.O. Box 511 • Barnstable, MA 02630 (508) 362-6823 111 Fax: (508) 362-0227 1 MEDIC Successful First Aid® Completion training programs Card Q/Pediatric(CPR inclusive) This Successful Completion Card is not valid if more than one box ❑ Care Initiator(CPR inclusive) is checked. f Name l'icAl RICA tr Issued X -Oto Expires 0`'p'6% This Successful Completion Card documents training in Child,Infant,and Adult CPR and basic first aid skills.Additional course content may be documented on Class Roster. �. E®'C Successful First Aide Comple#ion training programs ,Card IlJ Basic . with AED(CPR inclusive) This Successful Com ❑ Public A�ess Defib is not valid if more than pleto than o n Card • (CPR inclusive) rillatiOn is checked, one box Name • Issued oZ•g.Q(p This successful CompletionExpires a•�'•�g defibrillator Card is do (AED),and life-su cementation of training in Cp PPorting first aid. Ruse of an automated e xtemal • TOWN OF BARNSTABLE Health Division— 200 Main Street - Hyannis, MA 02601 GF ZHE Tp� FAXDate: July 19, 2006 BMWSrABLE, 9� �9• ,�� Number of pages including cover sheet: 3 ArED MA'S�' To Ms.Alice Pitcher From: ELLEN WADLINGTON Town of Barnstable Health Division Mail to: 200 Main Street Phone: 508-362-6823 Hyannis,MA 02601 Fax phone: 508-362-0227 Phone: 1-508-862-4642 CC: Fax phone: 1-508-790-6304 REMARKS: ❑ Urgent ❑ For your review ❑ Reply ASAP ❑ Please comment As discussed, your food establishment permit has been mailed. You need to talk with Licensing for the B&B license. The Health Department needs $150 ($75 each)from you for the pool and whirlpool. Your insurance certificate has arrived and you need to request the variance for the lifeguards. Attached is a copy of your last year's request and the info. needed for the qualified swimmers. If you have any questions, please call. 777 1• Lamb ana Lion Inn N C= March 1",2005 Town of Barnstable Board of Health 200 Main Street ^� Hyannis,MA 02601 Re: Qualified Swimmers Request Dear Board Members, The Lamb and Lion Inn is seeking a lifeguard modification for qualified swimmers to be used in our swimming pool. The Lamb and Lion is open year round with the use of the pool being from June- September. We are located at 2504 Main Street,Barnstable,MA. The Owner/Manger of the property is Alice Pitcher. The Innkeepers on site are Eric.Oickle and Laurie Wismer. We can be reached at 508-362-6823, with any questions or concerns. Sincerely, Eric Oickle Laurie Wismer Enclosures wwwlambandlion.com E-mail: info@lambandlion.com 2504 Main Street (Route 6A) • P.O. Box 511 • Barnstable, MA 02630 (508) 362-6823 • Fax: (508) 362-0227 I CRITERIA FOR GRANTING MODIFICATION OR VARIANC10FROM THE RECOMMENDATION OF THE STATE ENVIRONMENTAL CODE REGARDING SWIMMING POOLS AND LIFEGUARD RE UIREMENTS QUALIFIED SWIMMER• In constant attendance when pool is open. Only CPR certified personnel who have passed a swimming test shall be used at pool. A BRIEF LETTER MUST BE SUBMITTED YEARLY TO REQUESTr A VARIANCE FOR' i LIFEGUARD MODIFICATION IF HIRING QUALIFIED SWIMMERS INSTEAD OF LIFEGUARDS - ALONG WITH THE WATER TEST .RESULTS AND WITH THEE ENUMERATED A), B) AND C) BELOW. _ General Requirements: Swimming Test: The swimming test, administered by the operator of the pool, consists of: - Swimming 2 lengths of pool. - Treading water 5 minutes. - Retrieving an object from bottom of pool. A) WITH ANNUAL RENEWAL, SUBMIT TO HEALTH DEPARTMENT: CERTIFIED POOL OPERATOR CERTIFICATE. CPR Certification: The qualified swimmer(s) shall be 18 years of age or older holding a current American Heart Association or American Red Cross CPR certificate with training in child, adult, and pediatric CPR. B) WITH RENEWAL, SUBMIT CURRENT CPR AND FIRST AID CERTIFICATES. Familiarity With First Aid The qualified swimmer(s) must demonstrate familiarity with life saving equipment, including rescue procedures and administering first aid. Swi_ All qualified swimmers while on duty shall wear an orange hat or visor with the words "POOL STAFF" in 15 millimeter (5/8 inch) black colored lettering on the front of the hat. Pool Cayacity. The maximum capacity at the swimming pool site is restricted not to exceed 19 persons. Insurance; The insurance policy of the pool must name the Town as co-insured in the amount of $1,000,000. C),; Description: "Town of Barnstable is additional insured under General ' Liability as respects to the swimming Pool." and Certificate Holder must be listed as: "Town of Barnstable, 367 Main Street, Hyannis, MA 02601." And mailed to Health Department, 200 Main Street, Hyannis, MA 02601 Q:Health/WP/lifeguardmodificationReq L f �tNE Town of Barnstable • .�. • Board of Health �, o 1639. °� 200 Main Street Hyannis,MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Wane Miller,M.D. Sumner Kaufman M.S.P.H. May 9, 2005 Mr. Eric Oickle Lamb and Lion 2504 Main Street Barnstable, MA 02668 RE: Lamb and Lion, Lifeguard Modification for the Outdoor Swimming Pool Dear Mr. Pickle, We will allow you to employ a' "qualified swimmers," in lieu of the requirement to employ fully certified lifeguards, at your swimming pool located at the Lamb and Lion, 2504 Main Street Barnstable, MA. This includes persons in your pools and includes all other persons within the pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a "qualified swimmer" all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk unless another swimmer is provided and physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (2) All qualified swimmers shall wear orange colored hats or orange colored visors with the words "POOL STAFF" in 15 millimeter (5/8 inch) black colored lettering on the front of the hats. (3) The maximum capacity of the swimming pool is reduced to nineteen (19) persons. (4) You shall maintain a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. PoolLamb&Lion (5) You shall submit a copy of the applicant's insurance policy naming the Town as coinsured in the amount of$1,000,000. (6) All other regulations contained in Chapter V, 'Minimum Standards for Swimming Pools, must be strictly complied with. (7) The qualified swimmer must hold a current American Heart Association, American Red Cross, or equivalent CPR certificates with training in adult, child, and pediatric CPR. (8) The swimming pool water must be tested `for coliform bacteria at least monthly by a certified laboratory. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 2005. It is your responsibility to ensure that you request renewal of the variance from the lifeguard requirements each year prior to opening the pool. Sincerely yours, omas A. McKean, C.H.O. Health Agent BOARD OF HEALTH TOWN OF BARNSTABLE PoolLamb&Lion Y.. 2 Lamb ana Lion Inn j o -Y March 1",2005 Town of Barnstable Board of Health 200 Main Street N Hyannis,MArn w 02601 Re: Qualified Swimmers Request Dear Board Members, The Lamb and Lion Inn is seeking a lifeguard modification for qualified swimmers to be used in our swimming pool. The Lamb and Lion is open year round with the use of the pool being from June- September. We are located at 2504 Main Street,Barnstable,MA. The Owner/Manger of the property is Alice Pitcher. The Innkeepers on site are Eric Oickle and Laurie Wismer. 'We can be reached at 508-362-6823, with any questions or concerns. Sincerely, �-- Eric Oickle Laurie Wismer Enclosures www.lambandlion.com E-mail: info@lambandlion.com 2504 Main Street (Route 6A) • P.O. Box 511 • Barnstable,MA 02630 (508) 362-6823 • Fax: (508) 362-0227 From:David D.Rust At Drake,Swan and Crocker FaxID:20TT750339 To:Lamb&Lion Inn Date:02122105 09:58 AM Page:2 of 3 i ACORN CERTIFICATE OF LIABILITY INSURANCE CSR DT DATE(MMOONYYY) LAHBA-2 02/22/05 PRO13UCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI Drake Swan & Crocker ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lots Hollow Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO Orleans MA 02653 Phone:508-255-3212 Fax:508-255-9864 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Norfolk & Dedham Mutual INSURER B: The Lamb and Lion, LLC. INSURER C P.O. Box 511 INSURER D: Barnstable MA 02630 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE. POLICY NUMBER DATE(MMIOWYY) DATE MMDIYY) LIMITS GENERAL LIABILITY _ EACH OCCURRENCE $2000000 A X COMMERCIAL GENERAL LIABILITY R0206637 04/16/05 04/16/06 PREMISES(Eoccure ance) $50000 CLAIMS MADE.OCCUR MED EXP(.Anyone person) ;$5000 PERSONAL BADV INJURY $2000000 GENERAL AGGREGATE. $4000000 GEN'L AGGREGATE LIMIT APPLIES PER: C—\C_ ^'- PRODUCTS-COMPIOPAGG $4000000 X POLICY PET LOC — ------ l AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per acciderd) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-IA ACCIDENT $ ANY AUTO OTHER THAN, EA ACC $ AUTO ONLY: AGG $ EXCESSAIMBRELLA LIABILITY - EACH OCCURRENCE -$ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ - $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY - ANY PROPRIETORIPARTI,ERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? E.L.DISEASE-EA UFLOYEE $ It yes"describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT :$ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Bed and breakfast inn including swimming pool, located at 2504 Main Street, Barnstable, MA CERTIFICATE HOLDER CANCELLATION BARD s 1 SHOULD ANY OF THE.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRA71ON DATE THEREOF,THE ISSUNG INSURER WILL ENDEAVOR TO MAIL 10 DAYS YmTTEN Town Of Barnstable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Health Department IMPOSE NO OBLIGATION OR LIABILrrY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main St. Hyannis MA 02601 REPRESENTATIVES. AUTHOPoZED REPRESENTATIVE Drake Swan & Crocker Insurance ACORD 25-(2001J08) ®ACORD CORPORATION 1 d This recognizes that LAURIE WISMER o has completed the requirements for aADULT,INFANT AND CHILD CPR conducted by CAPE COD CHAPTER Date completed The American Red Cross reoaMMcate as valid for I year(s)firm completion date. This recognizes that. ERIC OICKLE has completed the requirements for ~ 4DULT,INFANT AND CHILD CPR V conducted by VA CAPE COLD CHAPTER Date completed 02/17/2005 The American Red Cross recognizes this certificate as valid for I year from completion date. y. ctor' Chapter CAPE COD CppiPTER Holder' t,w Cem 653999 Otm Oct,2601) Chairman,Ama& — ctor' pt Holder's Signature :, :_ sect.653999.(kev;:t ` This re .es that W h ERIC OICKLE v` o has completed the requirements for mV c a� Adult CPR conducted by CAPE COD CHAPTER Date completed • �� The American Red Cross recognizes gnizes this certificate as valid for 1 year(s)from completion date. Chairman,4Aeled Cross or Signa Chapter �H ® F v"Ed Holder's Signature T Lamb ana Lion Inn Town of Barnstable Board of Health Donald Desmarais Health Inspector 200 Main Street Hyannis,MA 02601 This Letter is to verify the Lamb and Lion Inn(2504 Main Street,Route 6A,Barnstable) does not accept children under the age of 12 years old while the pool is in service. If you have any other concerns regarding this matter you may contact me directly. ank-you, 'i Alice Pitcher,Propreitor www.ldmbandlion.com E-mail: info@lambandlion.com 2504 Main Street (Route 6A) • P.O. Box 511 • Barnstable, MA 02630 (508) 362-6823 1 Fax: (508) 362-0227 0 r oFtHETp�� Town of Barnstable ASTABLE. = Board of Health 9 MASS. �A 16.39. Aim 200 Main Street lED MA'S Hyannis, MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Wane Miller,M.D. Sumner Kaufman M.S.P.H. e Mr. Eric Oickle 2oay Lamb and Lion 2504 Main Street Barnstable, MA 02668 RE: Lamb and Lion, Lifeguard Modification for the Outdoor Swimming Pool Dear Mr. Oickle, We will allow you to employ a "qualified swimmers," in lieu of the requirement to employ fully certified lifeguards, at your swimming pool located at the Lamb and Lion, 2504 Main Street Barnstable, MA. This includes persons in your pools and includes all other persons within the pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a "qualified swimmer" all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk unless another swimmer is provided and physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (2) All qualified swimmers shall wear orange colored hats or orange colored visors with the words "POOL STAFF" in 15 millimeter (5/8 ,inch) black colored lettering on the front of the hats. (3) The maximum capacity of the swimming pool is reduced to nineteen (19) persons. (4) You shall maintain a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. P PoolLamb&Lion (5) You shall submit a copy of the applicant's insurance policy naming the Town as coinsured in the amount of$1,000,000. (6) All other regulations contained in Chapter V, Minimum Standards for Swimming Pools, must be strictly complied with. (7) The qualified swimmer must hold a current American Heart Association, American Red Cross, or equivalent CPR certificates with training in adult, child, and pediatric CPR. X (8) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 2004. It is your responsibility to ensure that you request renewal of the variance from the lifeguard requirements each year prior to opening the pool. Sincerely yours, Thomas A. McKean, C.H.O. Health Agent BOARD OF HEALTH TOWN OF BARNSTABLE PoolLamb&Lion n / �� �, C/r I �� �� �� R �3 .. _ � t Lamb ana Lion Inn June 7 h,2004 Town of Barnstable Board of Health 200 Main Street Hyannis,MA 02601 Re: Qualified Swimmers Request Dear Board Members, The Lamb and Lion Inn is seeking a lifeguard modification for qualified swimmers to be used in our swimming pool. The Lamb and Lion is open year round with the use of the pool being from June- September. We are located at 2504 Main Street,Barnstable,MA. The Owner/Manger of the property is Alice Pitcher. The Innkeepers on site are Eric Oickle and Laurie Wismer. We can be reached at 508-362-6823,with any questions or concerns. Sincerely, Eric Oickle Laurie Wismer Enclosures i wwwlambandlion.com E-mail: info@lambandlion.com 2504 Main Street (Route 6A) • P.O. Box 511 • Barnstable, MA 02630 (508) 362-6823 • Fax: (508) 362-0227 LAMBA-2 06/0 1 DATE(fv1M1OD/YYl'Y) a4C®R'D CERTIFICA10DF LIABILITY INSURA�I� eSR DR 3/04„ PRODUCER THIS CERTIFICAT oS ISSUED AS A MATTER OF INFORMATION Drake,5;tan & Crocker Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Aged cy, Inc. MOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 14 i,ot' s Hollow Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW L—.— --------- - - Orleans VA 02653 I Phone: 508-255-3212 INSURERS AFFORDING COVERAGE I NAIC# INSURED - ------ _----- NSIPEDrA Norfolk & Dedham Mutual 23965 The Lamb and Lion LLC. ; I•I~ P.O. Box 511 ` ------ -- --- -- ------- ---------f --- — Barnstable MA 02630 Jsll'E' L - -__-- !sI:�EPE I COVERAGES THE POLICIES OF INS'JRANCE LISTED BELOVJ HAVE BEEN ISSUED TO THE!NSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREL"ENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE"PERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -p-L-- � --- - -- -�TSOTIL`Y'ETFECTIG'E--Ts'JtiICYEk'F'iRATf0F1', — ----- — LTR tJS'RC� YPE_0_F INSURANCE v Y— POLICY NUMBER - - DATE(MMIDDIYY} I DATE(MMIDDM'} LIMITS I GENERAL LIABILITY a 2000000 A V 'CCi,,IME,CI,^ GE,1 FPL Li�f]LJTY R0206637 04/16/04 i 04/16/05 1 EqC _.(t -:cur ,. !� 50000 ,+ c.f.1 , P,DE !" :c"P.. I I MED E)(F fArnr i 2r= r'1 I w 5000` s 2000000 _ENErAL' r 1;4000000 9 ! GEJLrb,RE,=?T�LI',11T PPLIE� �F' I ! >; 4000000 _I-F T fD,- _ - I AUTOMOBILE LIABILITY - —�— — - --i I t'.�PaiEI1JEC�°IhfGLE Lr`dpT c - _ N RED TJ, I ,J ` Y I'dJUPY c ciderlt` rS I I I l:_'er� ci�iari} I GARAGE LIABILITY ----- —_ —v —V e UNJi.' -,E'IT J JT t TH"-:N " Tl GR'L4 q r EXCESSIUMBRELLA LIABILIT`! I OC:1 iq I 'LH N."yC E I q ro GATE —� f -- -- — —- L,EDI:, 7!ELE 1 I ! 777 WORKERS COMPENSATION AND I EMPLOYERS'LIABILITY _ I u 'LI i ER / 'P Pc iG4, PTI•!-G't'.EC�.'r't I i E L Fk -- - Lr=iCE ECtLLIF,ED� ( I �E �I ._, -i,,1-L,IYE%I E I, CLi I;'(.J h Inv: I :'I SE P:'LICY_'lilT f t IOTHER ! I ' I I i DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS — — —� Bed and breakfast inn including swimming pool, located at 2504 Main Street, Barnstable, 1,M CERTIFICATE HOLDER CANCELLATION + BARNSI7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER VVILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of Barnstable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Health Department IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGE*,- OR 367 Main St. Hyannis MA 02601 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �f/ L ACORD 25(2001108)• ©ACORD CORPORATION 1S Lamb ana Lion Inn June r,2004 Town ofAa astable Board of Health . 2001VMaiii Street Hyaris,.MA 02601 i Re: CPR/First.Aid Certificate - Eric Oickle and Laurie wismer are scheduled for retra nin'contacted at 508-362-6823 with an g June 22 ',2004. We can be y questi9nS or concerns. ..................:.. .. ......... Is Indicates that ... i ��s'� Av— CPR First Aid &Safety Services has successfully completed the designated progr h 1 This certifies that at the level of BASIC .R E— E.R' In accordance with the guidelines of the Heart an LAU R I E W I Q Stroke Foundation of Canada i . MER HEART Stroke successfully completed [FOUNDATION STROKE Date of Issue' 2 2/0 4/0 3 1 "Annual retraining is recommended trctlrllllg COUfSe 011 OF PRINCE- I WHMIs EDWARD ISLAND Instructor 1-2 /0 4/0 3 Late 1 r Recogn zed by the Occupetionel Vining Officer ' . E _ 8 Safety Dep4 0l P � I ��— lk ambindlion.com Main Street.(Route 6A) • P.O.'Box 511 Barnstable, IvlA 02630 E mail: info@larribandlion.com (508) 362-6823 Fax: (508) 362-0227 t!, to 1 .. .... r a• � 'i This recognizes that C N ERIC OICKLE ` c has completed the requirements for v V o Infant and Child CPR conducted by iv CAPE COD CHAPTER .. g, Date completed 07/10/2004 ~ The American Red Cross recognizes this certificate as valid for I year(s)from completion date. r Chahman, Red Cro ctor's Sig r f Chapter APE COD CHAPTER Mw Holder's Signature AA oFtKE ram, Town of Barnstable „AM �. = Board of Health 16g9. ��� 200 Main Street RFD MA'l A Hyannis,MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Wane Miller,M.D. Sumner Kaufman M.S.P.H. July 17, 2003 Revised August 26,2003 Ms. Alice Pitcher Lamb and Lion 2504 Main Street Barnstable, MA 02668 RE: Lamb and Lion, Lifeguard Modification for the Outdoor Swimming Pool Dear Ms. Pitcher, We will allow you to employ a "qualified swimmers," in lieu of the requirement to employ fully certified lifeguards, at your swimming pool located at the Lamb and Lion, 2504 Main Street Barnstable, MA. This includes persons in your pools and includes all other persons within the pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a "qualified swimmer" all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk unless another swimmer is provided and physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (2) All qualified swimmers shall wear orange colored hats or orange colored visors with the.words "POOL STAFF" in 15 millimeter (5/8 inch) black colored lettering on the front of the hats. (3) The maximum capacity of the swimming pool is reduced to nineteen (19) persons. (4) You shall maintain a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. PoolLamb&Lion (5) You shall submit a copy of the applicant's insurance policy naming the Town as coinsured in the amount of$1,000,000. (6) All other regulations contained in Chapter V, Minimum„ Standards for Swimming Pools, must be strictly complied with. (7) The qualified swimmer must hold a current American Heart Association, American Red Cross, or equivalent CPR certificates with training in adult, child, and pediatric CPR. (8) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 2003. It is your responsibility to ensure that you request renewal of the variance from the lifeguard requirements each year prior to opening the pool. Since e y yours, ayne filler M.D. Chairm n BOARD OF HEALTH TOWN OF BARNSTABLE 4 PoolLamb&Lion Revised August 26, 2003 CRITERIA FOR GRANTING MODIFICATION OR VARIANCE FROM THE RECOMMENDATION OF THE STATE ENVIRONMENTAL CODE REGARDING SWIMMING POOLS AND LIFEGUARD REQUIREMENTS QUALIFIED SWIMMER: In constant attendance when pool is open. Only CPR certified personnel who have passed a swimming test shall be used at pool. General Requirements: Swimming Test: The swimming test, administered by the Operator of the pool, consists of: - Swimming 2 lengths of pool. Treading water 5 minutes. Retrieving an object from bottom of pool. CPR Certification: The qualified swimmer(s) shall be 18 years of age or older holding a current American Heart Association or American Red Cross CPR certificate with training in child, adult, and pediatric CPR. Familiarity With The qualified swimmer(s) must demonstrate First Aid: familiarity with life saving equipment, including rescue procedures and administering first aid. Swimwear: All qualified swimmers while on duty shall wear an orange hat or visor with the words "POOL STAFF' in 15 millimeter (5/8 inch) black colored lettering on the front of the hat. Pool Capacity: The maximum capacity at the swimming pool site is restricted not to exceed 19 persons. Insurance: The insurance policy of the pool must name the Town as co-insured in the amount of$1,000,000. PER ORDER OF THE BOARD OF HEALTH Wayne Miller, M.D. Susan Rask,R.S. Sumner Kaufman,M.S.P.H. Q:Health/WP/lifeguardmodificationReq 1.i��G :`� ?4EJM EFFikC=TH�•3C'HF'' OF HEALTH NO,F,0? P. 1. 1 t 9ANN9 6(.V, Arl%6 RIM BY 99 'down ofBarnstable,,,,,,,, Board of Health 200 Main Street, Hyminis MA 02601 OMCO: 308.362'4644 Sus4a G.Raslc,R.S. 509-790-6304 �i 1� / ►O.� f � Sumner Xaufmw W.M �►�/ �� L�1 /v Wayne A.Wiler,M.D.' StSo q _. YY�, `v�-S+r-ee Property Address: Assessor's wrap and Parcel:�tltnher: Sizix of Lot:_ etlaads'%Vit•l in 300 1. 'des Euskiess Narna ,'+7ty _._ Subdivision N4me;�_ APPLi�'A T'S NAiVE: 6 M Z�l�h - - �' one ���.�36 o+aner of the property e,.athorize yott to rep sent him or her? 'Yes No Addr3sm: aS0 � ai_ � l[r�( ae Addreiss: `Ljj9- Oa(�3o Phorie: 368�> Phone- VARIANCE,_ 4�.0M REGUI A.TIO (1w�ctie,.) _A•SO .(3 F C� may a tech ifmorc spa a needed) . 1 ' . .r.eau...arrrrrrr.r�v�....�.--v..v...-...+•n _—_ ..-...—.-^ _-�__ •r�rr _._—._ _- _-_.�..-M-u' NALTURE OF WORT, House Addition House Renovation M Repair of hailed Septic System chejzkl (to be con npleted by office staff person receiving varianc9 requo t&,pplicatton) Four(4)copies of the completed varlanre request fanr, Fcv-s(4)k;upies of engiatered plan subinitted.(e.g.septic system plans) Four(4)copies of lsboled d`unemion:d floor plats submimd(:,s.house plans or restaur'.7. :dtehea plems) Signed letter stating that the prop"owutr authorized you to represent hWper for tw.,3c request + Applicant understands that the abutters must be notified by certified mail at least ten days prior to ruettig date st epplleaat's expense (for Tait V Rnd/or tout%wagc regulation variances only) _ Ftill rneuu subraitmd(for grease trap variance requests only) vatiance request application fee collected (to fe, rot lift.-ttard modification tenowals, gnuzc trap variance tenewals (same bwno:/leasee only),ou!slde dWaS variance renewals[same ownerileasee oray],and variances to repair failed sewage disposal Symms (oily if ao expansion to the bullding proposed)) _ Variance request Wa nutted at IcUlt 15 days prior to meeting date VAItWSM AP1btWNIM Swan O.Rask,R.S„Chairman NOT APPROVED � SUM=KAtIftnan,M.S.P.it, RFASO9 ;FO t DisAPPl O VAI>,,,„��,,,,._ Wayne A Miller,M.D. Q:�IdEAI.^H\Ap�lfcatic:t 1"crtns�VAP.IR1yQ.bOC ' j '. ��•4�.�- -- - 'R DATE(MPdfDOiVY) I' AC RD CEIRTiF9C��E_�F LiA�_I_�.iT� ii_VU_RAiVC' OP ID A _-,E I.A1 BA 2 �vl_ 06/26 03 PRODUCER, :—" ! Y THIS CERTIFICATE IS ISSUED A'' ATrER OF INFORMATION Drake,SWan� -11 rocker Insurar^e ONLY AND CONFERS NO RIGHt�DPd THE CERTIFICATE Agency, :tic. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I f� INSURERS AFFORDING COVERAGE INSURED -.- Norfolk & Dedham Mutual The Lai-, and Lion, I:L•C• ---- -— --- ---- ---— ----- - - -- - -- s-osa Al ief- her _ -_ _....------ -- .__-____..- -------------•--- _________-- --- P.O. rl Ba1TJ, t,A 02630 =-- -- --- - ------- COVERAGES THE POLICIES Or IP SL:Rri..-; -ISTED EELCVV HAVE BEEN ISSUED TO TI-!E INSURED!QAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING~ ANY REQUIREMENT TERM(.jti"•ONDfT'ON OF ANY CONTRACT OR rO—HER DCCUNIFNT WITH RESPE---T TO INHICH THIS CERTIFICA"E MP:Y BE ISSUED OR . MAY PERTAIN THE H JS:vRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS 9.ND CONDITIONS OF SUCH POLICIES.AGGREGATE.LJ!.41TS SHOI.^!N i,,IAY^iAVE BEEN REDU�-ED BY PAID CLAIMS. INSR ---- -- - -- - -- -----._._.- _ POLICY EFF--tit P OLiCY E X IRA ,-T;J. _T -'-- ----- LTR I TV 5,DANCE POLICY NUMBER �Dr-_E Ot 4 O —LIM_LTSt_GENERAL rY _ ;ca.�.,=',r _.}2000000 A g ;:,". _ R0206637 04/1.6/03 04/1.6/04 =" _, 50000 - w 5000 -- -- i X .BOLA k ornr - - 000000 - - 4000000 _ -_" 7- r 4000000 , _ - AU70MC3ISE_;P.BMTY y = •NJ';>_ f , 5 WORKERS COMP'ENSAT-O!I - EMF--OYERS'LIAEILfrV i DFSCRiP'i1DIJ OF'OF FRA T 01-44SILOCATIOPISfVEHIC-LE SJ'EX CLUSiOIJS;DDEO BY E F40ORSEMEi I T f S PECIAL FR011S 10NS ~- ^_._�.._._. _— --• Bed and Breakfast including SWi.mning Pool located 2504 Hain Street, BarlLstable, MA. 02630 CERTIFICATE HOLDER AT A.DOMONAL INSURED:INSURER VETTER CANCELLATION BARITS 1'7 i S;i0t.1.0,-nit OF TF.r.:AS 71 IS DES C RIZiEO POLICIEw 6 CANCEL.SO BEFORE THE:E,1PI,RATI,'N-` DATE'HEREDF,THE Is S'11NG INSUR,ER+ALLL TO NWL Q,.__DAYS WRITTEN Town Of Barnstable j NOiICE'TO THE CERTIF!C-ITE HOLDER,*LAMED?O THE LEFT,SUT FAILURE TO OO$O SHALL Health Department !II IAAPC,E PJO OBL GATIOE)OR L1rSILff'i OF ANY KIND UPON'rHE INSURER,ITS AGENTS OR 367 Main St. Hyannis IAA 02601 REPRESENTATIVES. -AUTHORIZED REPPESEI•:TZTiVc . ACORD 25-S(7/97) _ - __ ,`~ ACORD CORPORATION.1388 r + �y This recogniz t This recognizes r' gnizes that / o � o j O o has cpe .ereq ments for v O has comD ugda McHu16V ete re ements for �p 51 Adult,Child and Infant CPR m V a o First Aid conducted by qa� N conducted by BRAZOS VALLEY CHAPTER BRAZOS VALLEY CHAPTER IT Date completed 11/09/02 erg, Date completed1: + ]1/09/02 The The American Red Cross.recognizes this certificate American Red Cross recognizes as valid for 1 year(s)from completion date. as valid for certificate 3 Year(s)from completion date. Chairman,Amer An Red Cross Instriict0l's'$ignature Chairman:qlmr.,J6ed Cross Instructor's Signature �RAZ�S` ALILTY ZOS VALLEY Holder's Signature ` " . Holder's Signature a f " k { �p�OFTHET TOWN OF BARNSTABLE OFFICE OF 11Aaa9TSBL i BOARD OF HEALTH OD i639. \�0 367 MAIN STREET .fa MP HYANNIS, MASS.02601 June 8, 1999 Alice Pitcher The Lamb and Lion Inn 2504 Main Street Barnstable, MA 02630 Dear Ms. Pitcher: Re: Your outdoor swimming pool - Former Bather Load Capacity 26; Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of 19 persons at your swimming pool located at The Lamb and Lion Inn, 2504 Main Street, Barnstable, MA. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediactric CPR. (7) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1999. Sincerely yours, /usan G. Ras1 , R.S. Chairperson BOARD OF HEALTH TOWN OF BARNSTABLE SGR/bcs Enclosure r 06/01/1999 23:47 5083624843 ALICEPITCHER PAGE 01 .a� I ` THE LAMB AND LION INN 1n,lkccper fl c Ajo i „t,r drr,chat 'i his c a•rtitil's Ihat ALICE PITCHER ALICE PITCHER I!.i. nvl,IrC,i r:r rl•tIuircmkv(N ror • � hay camplt-tcd tlx-rcquin•nu•nt%tirr �'f i`t).ARI►FIRST AID COMMUNITV CPR `p,)n.1md hy rm r rn-,(;NATTER CAPE COD CHAPTER 1)atc u,mptrtc@ MAY 2 5 1999 '^ c"titic,that (v/�] 1110HAS DOTT � � i,. , •., ,r.J tl,r nttuiretut•nt�tilt • � � �t�11�f1'Y GPR i •�•,,n.�rt•tl hr CAPE COD CHAPTER .,t, ,tmplrcrll MAY 2 5 1999 P.O. Box 511 •251 4 Main tit (Routc 6A)Barnstable.MA 02630 (508)3621tx23 Fax:(508)%2.4)227 f --- --a— 92 09 x 33 x 4Z 1 999 Pa��� 2 AcoRD CERTIFICATE OF LIABILITY INSURANCE CAR DATE(/ Y) LAMBA—A-2 06/02/99 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Drake,Swan 6 Crocker Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot's Hollow Rd.,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 Phone: 508-255-3212 INSURERS AFFORDING COVERAGE 04SURED INSURER A: Utica Mutual (.t INSURER B: i The Lamb and Lion, LLC. Alice Pitcher INSURER C: P O Box 511 INSURER D: Barnstable MA 02630 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLIOYEFF-THE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER. DATE(MWDD/YY) .DATE(MMIDONY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A COMMERCIAL GENERAL LIABILITY BOP2982301 04/16/99 04/16/00 FIRE DAMAGE(Any one fire) $100000 CLAIMS MADE ❑OCCUR MEO.EXP(Any one person) - $10000 $ BOP PERSONAL&AOV INJURY $1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $1000000 POLICY JEC�f LOC AUTOMOBILE LIABILIP/ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accitlenq ALL OWNED AUTOS • BODILY INUURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per eccid-t) PROPERTYDAMAGE $ (Per aCClAent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAA.CC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WC STATU- I OTT+ WORKERS COMPENSATTON.AND TORY LIMITS ER EMPLOYERS'LABILITY E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POUCY LIMIT $ OTHER. DESCRIPTION OF OPERATIOPIS/LOCATIONSNEHICLES7EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Bed & Breakfast 9-12 Units with swimming pool CERTIFICATE HOLDER N ADDITIONAL INSURED,INSURER LETTER. CANCELLATION BARNST 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of Barnstable 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE ATTN: Health Dept. 367 Main Street LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF Hyannis MA 02601 ANY KIND UPON THE INSURER.,ITS AGENTS OR REPRESENTATIVES. ACORD 25-S(7197) ACORD CORPORATION 1988 Wed Jun 02 09 :33 :42 1999 Page 1 Orake,Swan&Crocker Insurance FAX14 Lot's Hollow Rd.,PO Box429 Orleans,MA 026S3-0429 Date 06/02/99 Number of pages including cover sheet 2 To: From: Glen Harrington Paula D Gillespie Barnstable Board of Health Phone 508-255-3212 Fax Phone 9,15087906304 Fax Phone 508-255-9864 RE: Lamb&Lion LLC ❑ urgent ❑ For your review ❑ Reply ASAP ❑ Please comment Certificate of Insurance as pertalns to swimming pool. Paula,Orleans, MA Wed Jun 02 09 :33 :42 1999 page 3 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does_ not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(7197) 1 TOWN OF BARNSTABLE Bpi TH E TO w OFFICE OF HAH39TAn s BOARD OF HEALTH MAB&i639. 367 MAIN STREET �0MAR HYANNIS, MASS.02601 July 22, 1997 Donald McKeag the Lamb & Lion Route 6A Barnstable, MA 02630 Dear Mr. McKeag: Re: Your outdoor swimming pool - Former Bather Load Capacity 26; Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of 19 persons at your swimming pool located at The Lamb & Lion, Route 6A, Barnstable, MA. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediactric CPR. (7) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. i You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1997. Sincerely yours, ��— usan G. RasOR.S. Chairman BOARD OF HEALTH TOWN OF BARNSTABLE SGR/bcs Enclosure r- Tun 26 13 :40 : 19 1997 .,• Paee 2 `[ �:�..... D T! MMl <. A CORD,�,....�`rT" �CiI�1kT' •.F ; "' ' � 5RolA it.....:::::: 06/26/97m PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER,THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 14 Lot's Hollow Rd.,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE_ Peter G Walther 1 COMPANY Phan*No. 508-255-3212 Fax No. I A Utica Mutual INSURED }— CCMPANY B Donald P. McKeag DBA The Lamb COMPANY & Lion C P 0 Box 511 r ----- Barnstable MA 02630 ccMPauv :................................................................................. � D C'Dlilat4i laffi.:. ... .:::::::::::....::::::::::::::::::::::::::... .. ... THIS IS TO CERTIFY THAT.T. ...................................... ............................................•...............................................................................................•.•.•.•.•. :.•.• HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 138UEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 188UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OFINSURANCE I POLICY NUMBER POLICY EFFECTIVE, POLICYETCPIRATION LIMITS DATE(MM;DD�DATE(MM/DDJYY) I GENERAL LIABILITY 3ENERA:A30RE34TE B 1000000 A iCOMMEPUALGENERALLIABILITY SOP1971626 02/09/97 02/09/98 1000000 i:::.:::; I C!AIMS,V.AOE 7 CCOUR PERSONA-&ADVINJL'RY 3 1000000 OWNER'S&CON T RACI CR'S PROT EACH OOCL'RRENCE 6 1000000 X B0� i F!PE DAMAGE(Anv one hn) $ 50000 I VIED EXP;Any one perenn) s 10000 i AUTOMOBILE LIABILITY j C ANYAtJTC I OMBiNEDBIN3LE'!MIT �f ALL OWNED AUTO$ BCD!LY iNJ�RY r— IPer person $ �— SCHEDULED AUTOS L_ I LI HIPED A'JTCB I— I NON OWNED AUTOS I 807LY NJURYi°er accldenp S �— - I PROPERTY DAAAAOE b I I I GARAGE LIABILITY AUTO ONLY-EA ACCIDENT �$ ANY AUTO ! I OTHER THAN A:;TC ON.Y! EACH ACCIDENT 5 A33RE34TE 8 EXCESS LIABILITY j EACH OCCURRENCF UMBRELLA.OgM I i A,GGRE:ATE f OTHER TriAN UMBRELLA FOAM 15 WORKERS COMPENSATION AND WC eTATU OTN .......` ... >:•:•:•:•:•:•: EMPt3g!S1 LIABILITY EILEACRAQQQLNT 6 THE PROPRIETOR/ �i INCL EL DISEASE-POLICY LIVIT I IIIPARTNERS/EXECUTIVE OFFICERS ARE: FXCL I EL 015EI A9E-EA EMPLOYEE $ OTHER A� BOP SOP-197-1626 02/09/97 02/09/98 BUILDING 590100 -- PROPERTY 75000 DESCRIPTION OF OPERATION S/LOCATIONSNEMICLES/SPECIAL ITEMS Additional Insured regarding Swimming Pool: Town of Barnstable, Health Department, PO Box 534, Hyannis, MA. 02601 .....•.....•.•.•.•.•.•.•.•. .-. .•..•.•.•.•.•.•...•.•.•... ..•. ..•.•.•..•.•..•.• CSEi13FICk18:FiCtflSFt: >: :'>::':: BARNSTI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B!CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT, TOWN of Barnstable 1O ATTN: Health Department BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIQATION OR LIABILITY 367 Main Street PO Box 534 OF ANYKIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. Hyannis MA 02601 AUTMO-•ZED TIVEE , ::.•....:....•...•..:•..:....: .. .:. .:.. :.�4 Q;FtCt:��� :i � :•:•:•::< :•:;:•:;:•:•:•:•:•:•:•:•:•:•: :•:•:: :;::.:.:.:.:.:.:.:.:.:.:.:.:.•.:.•. :.•..,.•..•.•..•.•.•.•:.•.•.•:.•. �ACt3RC1:Ct RiP.QPtA lal�1489:: l.: THE FOLLOWING IS/ARE THE BEST . IMAGES, FROM POOR QUALITY ORIGINAL (S) M ,�-A . DATA 05/09/1991 08: 17 5083.624843 DON MCKEAGUE PAGE 02 ` V A THE LAMB AND LION INN Donald P. McKcag `.r�U�� / L� / innkccper / 10 ts 0C I Y- 111, _._ -- ; ti 7:7(5 -X4 -/C.._ �://1Z.�, 1, L cardiunulnto�ktry ( � Kt�u+;c►halion anti American Heart h n►crgency AssociaCion-�W Cardiac Cult ' Rgbffng Noon D1a8499 � Njivider en0 SfroRe L.E.. Donald P. McKeag t , has participated in an American Heart Association 1 �'1 ✓� 1 Heansaver Course. B-L eve 1 —0 7/0 7-42Z.— RecpmMe 7 He�ewal Dnle Iwo Date I I Name of American Mean Association Inslr Na r F hl a I.D.r6a0U7 H ;:° •Y '' Holders � Signdlure TMy "niuo act pfomaon S'o hft-to ne of apo'.Chote• c WOV199 anp uq�nang ncf. V994,Arnerlcen Hvtttl A3socia it❑im prnslablc. MA 0..1630 (50A)167-61R21 Fax. (508)362-0227 • TOWN OF BARNSTABLE THE OFFICE OF = BARTSTABL BOARD OF HEALTH MA88. °o 1639- \00 367 MAIN STREET �0 MAY k HYANNIS, MASS. 02601 June 4, 1996 Joanne Rice The Lamb & Lion Route 6A Barnstable, MA 02630 Dear Ms. Rice: Re: Your outdoor swimming pool - Former Bather Load Capacity 26; Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of 19 persons at your swimming pool located at The Lamb & Lion, Route 6A, Barnstable, MA. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool f is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and ped You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1996. Sincerely yours, Susan G. Rask, R.S. Chairman BOARD OF HEALTH TOWN OF BARNSTABLE SGR/bcs Enclosure �acORo CERTIFICATE LIAB1LITlf INSIRA SR HS DATE(MMI°°/YY) ONA 11.. .: :. 05/02/96 .:..::. _. .>: PRODUCER .. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Drake, Swan & Crocker HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot's Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE Ross D Goslin COMPANY Phone No. 508-255-3212 Fax No. A Utica Mutual INSURED COMPANY B Donald P. McReag DBA The Lamb COMPANY T&_L-o C 2504 Main Street COMPANY Barnstable MA 02630 D COVERAGES _:..- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERPJI OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS TR DATE(MMIDDNY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 1000000 A COMMERCIAL GENERAL LIABILITY BOP1971626 02/08/96 02/08/97 PRODUCTS-COMP/OPAGG $ 1000000 CLAIMS MADE OCCUR PERSONAL 8 ADV INJURY $ 1000000 OWNER'S B CONTRACTOR'S PROT EACH OCCURRENCE $ 1000000 X BOP FIRE DAMAGE(Any one fire) $ 50000 MED EXP(Any one person) $ 5000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WC STATU- OTH WORKERS COMPENSATION AND TORY LIMITS - ER EMPLOYERS'LIABILITY EL EACH ACCIDENT $ THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESISPECIAL ITEMS Additional Insured regarding Swimming Pool: Town of Barnstable, Health Department, PO Box 534, Hyannis, MA. 02601 CERTIFICATE HOLDER .: CANCELLATION BARNST1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY ATTN: Health Department 367 Main Street PO Box 534 OF ANY KIND ON T ECOMPANY,ITSAGENTSOR PEPRESENTATIVES. Hyannis MA 02601 AUTHORIZE ATIVE ACORD 25-S:(1/95) .. ACORD CORPORATION 1089 r � I Cardiopulmonary Resuscitation and American Heart Emergency Assoclation,i Cardiac Care Fighting Heart Disease Provider and Stroke Donald P. McKeaq has participated in an American Heart Association HeartSaver Course. BLS—B 5/22/96 5/ 2/97 Issue Date Recommended Renewal Date Name of American Heart Association E mer ciency Medical Teachir Instructor's Services, Inc. Name 2 Chadwick Road Instructor's South nni , ! 2660 I.D.No. Holders Signature - This recognition is subj ct to the provisions and r itati s of applicable state statutes and licensing acts. ©1994,American Heart Association 70-e153 TOWN OF BARNSTABLE �Di THE r'o bo,Q .� ♦o, OFFICE OF HARNSTABL s BOARD OF HEALTH 1639' 367 MAIN STREET Mny k HYANNIS, MASS. 02601 June 20, 1995 Joanne Rice The Lamb & Lion Route 6A Box 511 Barnstable, MA 02630 Dear Ms. Rice: Re: Your outdoor swimming pool - Former Bather Load Capacity 26; Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of 19 persons at your swimming pool located at The Lamb & Lion, Route 6A, Barnstable, MA. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and ped iatric CPR. (7) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. r You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1995. Sincerely yours, /usa'n G. Zs(,I.S. Chairman BOARD OF HEALTH TOWN OF BARNSTABLE SGR/bcs Enclosure L David&Joanne Rice .fib [O�11 Innkeepers 508-362-6823 `i3atKstable June 5 , 1995 Board of Health . Town of Barnstable South St . Hyannis , Ma . , 02601 Gentlemen: We hereby request a variance to operate a semi-public swimming pool in accordance with all the rules that apply as we have complied with the past ten years . I am enclosing my-community CPR certificate and you have our million dollar insurance certificate on file . Most cordially, AMB & LION INN Joanne E. Rice Innkeeper .THE LAMB AND LION Route 6A-Main Street P.O. Box 511 Barnstable, Massachusetts 02630 4' American Heart Association Cardiopulmonary Resuscitation and Emergency Cardiac Care Joanne Rice has successfully completed the national cognitive and skills examinations in accordance with the Standards of the American Heart Association for BLS-B 2/7 /95 2 7 Z 9 6 Date of Expiration Date of Issue ISSUE DATE(MMIDD/YY) CERTIFICATE 0 INSURANCE ,A ;(MM/DD JRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SWAI\I & CL?0(,Kl:::I? I NSi . A(l(,Y COMPANIES AFFORDING COVERAGE l)0 BOX 1129 Olt 1...1 A l\I!) MA 0 2 O±:7 3 COMPANY LETTER A U f I CA I\IA1 101\IA1... I N 1.)RAP!CL (:IR0U1) COMPANY B INSURED LETTER ,10A1\11\11:: & D A V 11.) 1'? 1 CI: COMPANY LETTER C 1)13 A 1111::: 1...A M L3 & L.. 101\1 11\I N 1') 0 130X r)-1 1 COMPANY L3 A It nl Si T'A L31...L MA 02630 LETTER D COMPANY E LETTER COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) A GENERAL LIABILITY T 0 13 I::: 1 S):)(.)I:::L) f3 () I �)�L f3 () 1 9 15 GENERAL AGGREGATE $ 2000 , 000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 2 0 0 0 , 0 0 0 CLAIMS MADE X OCCUR. PERSONAL&ADV.INJURY $ '1 0()() 0 0 0 OWNER'S&CONTRACTOR'S PROT.' EACH OCCURRENCE ! $ '1 0 0 0 e 0 0 0 FIRE DAMAGE(Any one tire) $ MED.EXPENSE(Any one person) $ '1 0 0 O O AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO i ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) j $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) ' $ I GARAGE LIABILITY ! PROPERTY DAMAGE $ i EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATEp j $ OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT $ AND DISEASE-POLICY LIMIT $ EMPLOYERS'LIABILITY DISEASE-EACH EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS cr:Ft 1 I I I CA fE: HOL-DL::L? IS f 0 1:31:= MUI\I I C I L)AI... 1 1Y AS Al"1) 1 T I ONAI... I NS(.)R[::I:) FOR :- SW I MM I N(i f)001.. ON PRL::M I Sl::S ONLY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO i OW 1\I ()I::: 1:3 A I?N S) I A 13 i...I::: MAIL 1 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 1-1FA1_1 11 1:::L)A14 1..M1:::h1 L LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR I'11'A hl 1\I I Si MA ()2(i()..1 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE c id L)F�T1:::R (:I WAl..-rHL::It ACORD 25-S(7/90) C ACORD CORPORATION 1990 Of TOWN OF BARNSTABLE 6 y0f THE Taw ��Q� • �� OFFICE OF BAWST"L i BOARD OF HEALTH i639' 367 MAIN STREET CEO MpY�' HYANNIS, MASS.'02601 June 7, 1994 Joanne Rice The Lamb & Lion T Route 6A. P.O. Box 511 Barnstable, MA 02630 Dear Ms. Rice: Re: Your outdoor swimming pool - Former .Bathing Load Capacity 26 Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of. 19 persons at your swimming pool located at Rte.6A, Barnstable, MA. This includes persons in,. your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: ( 1) The pool must be supervised by a swimmer, by you at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the 'front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed) . (2) You must keep a permanent record on a form prescribed_ by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample' of prescribed form _k5 is enclosed. ) (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4 ) All other regulations contained 'in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. k [w q f , (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediatric CPR. (7 ) The swimming pool water must be tested for coliform bacteria at least -monthly by a certified laboratory. You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1994. Sincerely yours, Brian R. Grady, R.S. Chairman BOARD OF HEALTH TOWN OF BARNSTABLE BRG/lls Enclosure Iwo Bakwtable l_ May 31 1994 Board of Health Town of Barnstable Town Hall Barnstab County- Hyannis , Ma . To Whom it May concern: We hereby request a variance to operate a semi-public swimming Pool at our Inn in accordance with all the i rules that apply as we have for the past 9 years . I am enclosing my Community C.P.R . certificate and you have on file our Million dollar insurance certificate. C / dially, n e � Jnnkeeper MAILING ADDRESS: Box 511, Barnstable, Mass. 02630 a 617-362-6823 l f - f • Amen Heart Association • Cardio onary Resuscitation and Emergency Cardiac Care �Jnanne Rice has successfully completed the national cognitive and skills examinations in accordance with the curriculum of the American Heart Association for BLS—B ._ 01/26/94 01/26/95.': .' Date of Issue Date of Expiration u0i1e130ssdae8H ue31aauad -- 1 :w 6u1sueoll pus senlets elels elpopdds - p suopellwll Pue suolslnad ey1 of t*l ns sl uopeldwoo ewnoo Inlsssoms to uopluBoosil- r emieu Ig y _ s,JeploH s 'ON•0-1 sh ,Jo3ruiissuull VW �INN36 u s71t os aeiteiueseudey mosey useH uoliepoesy>JeaH io GLUON a3elllalV a 3 ' �•, 3 s� ... 6ua9n40BSSVW - {. V. p f ' MtrOl•1 CERTIFICATE INSURANCE ISSUE DATE(MM/DD/YY) F1 7 ?_9 74 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1:)111 A K I:- S W A 1\I & C f?01(,K F? 1 1\I S , A(3 N COMPANIES AFFORDING COVERAGE 1)0 130X 42::1 01-31...1:"AIMS MA 02653 COMPANY LETTER A U f I CA 1\IA..I.. 10NAI... I NSU1:?A1\1CF CIF?0I.1F) COMPANY B INSURED LETTER ,10A1\11\11::. & DAV 1 D 1* i COMPANY c I)13 A 11"11: 1...A M 13 & I... 101\1 11\11\1 LETTER ........................ ........ F) 0 13 0 X 51 ,11 COMPANY D F.3A1?1\1STA131._1 /_: MA 0630 LETTER COMPANY E LETTER COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, __EXCLU_S,IONS A.ND_CONDITIONS OF_SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID.,CLAIMS,___ . . . ..__,_.,,.. COj _ POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) 4 LIMITS /1 GENERAL LIABILITY 1 0 13 1 1 S S I.J I:::L) 8 0"1 9/11 +3 01 9 GENERAL AGGREGATE S 2000 , 000 X .COMMERCIAL GENERAL LIABILITY I PRODUCTS-COMP/OP AGG. $ 2000 000 L.._....._.._3 ..........___...__........_.._._..............__.__.........._.........._................. _._____c___..._....-...--._7__-.-----._.... j CLAIMS MADELX OCCUR. PERSONAL&ADV.INJURY $ "1 0 0 O � 000 _ . OWNER'S&CONTRACTOR'S PROT.E ( EACH OCCURRENCE $ 1000 � 000 FIRE DAMAGE(Any one tire) $ I MEEXPENSE(Any one person) $ 10 0 0(I AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO - LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS j (Per accident)dent) - GARAGE LIABILITY - I IPROPERTY DAMAGE $ i EXCESS LIABILITY I ! EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION ; I STATUTORY LIMITS EACH ACCIDENT $ AND E....................._...:................_.._............._................................_..........................._............. .. € (I DISEASE-POLICY LIMIT $ EMPLOYERS'LIABILITY m DISEASE-EACH EMPLOYEE $ OTHER E I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS l i0 L.L)F F? IS 1 0 131: M I.11\I I (, 1 1)A I... 1 .1_Y AS A I:)D I -1- 1 01\IA 1 11\I S(.J I;I::.I:) F::01? 1-H F S W I M M I lu(3 F)0 0 L.. 01\I P R F::M I S F::S 0 I\!I...Y. CERTIFICATE HOLDER ,CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO I 0 W 1\1 01:: 1.3 A 111\1 S'T A 131._F MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 1-11::A L..'T 1.1 1:)F::F)A F?1"M 1:::1\1_I. n LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 1) 0 130X 'i 34 I IYA i\I I\1 I S MA U!6 01 LIABILITY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE V F)1::: 1I:::13 . 3, WA1...1.11113 45 ,;A) ACORD 25-S(7/901 C AGORD CORPORATION:1990 TH E TOWN OF BARNSTABLE OF t0 re�'Q�w �ya OFFICE OF BAaa9TaBb s BOARD OF HEALTH MABEL 00s,1639' `gym 367 MAIN STREET .EC MPY k" HYANNIS, MASS.02601 June 15, 1993 Joanne Rice The Lamb and Lion Route 6A P. O. Box 511 Barnstable, MA 02630 Dear Ms. Rice: Re: Your outdoor swimming pool - Old Bather Load Capacity 26 Outside; Modified Bather Load Capacity - 19. We will allow you to set a maximum capacity of 19 persons at your swimming pool located at Rte. 6A, Barnstable, Ma. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American. Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the _pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) .All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for .coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediatric CPR. (7) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. r You are granted this modification of your present pool capacity of 26 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1993. Sincerely yours, usan G. RasiR.StA Chairman BOARD OF HEALTH TOWN OF BARNSTABLE SGR/bcs Enclosure - _ • David &Joanne Rice tCFK Innkeepers 508-362-6823 V� i r,' rBakK:table June 1 , 1993 Town of Barnstable Board of Health Main St . Hyannis , Ma . , Dear Sir , We hereby request permission to operate a Semiprivate swimming pool in accordance with all the rules and regulations . Enclosed please find a copy of our Community CPR Certificate and our insurance policy covering the pool . Thank you for your attention to the above . Cordially, Joanne and David Rice .Inkeepers THE LAMB AND LION Route 6A—Main Street P.O. Box 511 Barnstable, Massachusetts 02630 S. e r American Heart Association . x €i � ; Cardiopulmonary Resuscitation and Emergency Cardiac Carean. JOANNE ? krwr R I has successfully completed the national cognitive and skills examinations in accordance with the curriculum of the � .American Heart Association for . i BLS—B ' 1/28/94 Date of Issue _ _ Date of EAV xpiration a ; asx r .14 t. e E a t '. s r r, Ar TM � ` 4' Massachusetts Affiliate Hearl Assoc.Repreaentetive Name of Heart Assoclatlon EMTSr INC. r¢# r ¢y Instrueto�s Name Instrue ,r's I. .No. + Holder's ¢ Slgneture On "Y nition of successful course completion Is subj } ect to Me provisions and Iimdatlona of r gpplicable state statues and licensing acts. American Heart Association r ., �. �. � ,III,II e t ry CERT151 . ` J)"�E•�S V C ISSUE DATE(MM/DOv) 7/21 /92 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS The Fredericks Ins . A e n c I n . NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND. 9 Y C EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 1046 Main St . - P. O. Box 427 Ostery i 1 1 e Ma . 02655-0427 - COMPANIES AFFORDING COVERAGE LEMTERY T A The Travelers Ins . Co . COMPANY, INSURED LETTER David J . & Joanne Rice d/b/a COMPANY LETTER C The 1am.b .and Lion P . O. b o x 5 1 1 OMPA Y D Barnstable , Ma . 02630 COMPANY E LETTER COVERAGES .F"TWAT?H"PCN !K-A OF INSURANCE LISTED SELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY AEOUIREMENT.TERM OR CONDITION OF ANY UONTRAC 0A OTAER DOCl.'.4 ,.E . ::'irn;LSr'FCT T.0 "`- -.`IC u THUS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS LTR DATE(MM/DO/YY) 'DATE(MM/ODNY.) _ -GENERAL LIABILITY - GENERAL AGGREGATE $ , 000 X COMMERCIAL GENERAL LIABILITY o/ i/g 2 0/ i/g B PRODUCTS•COMPIOPS AGGREGATE f 2 , 000 ' O O O CLAIMS MADE OCCUR. I 6 S O-2 5 i K 2 5-3 O v PERSONAL&ADVERTISING INJURY S OWNER'S a CONTRACTOR'S PROT. C O F—9 2 EACH OCCURRENCE 3 1 ' 0 0 0 FIRE DAMAGE(Any one fire) S 50 MEDICAL EXPENSE(Anyone person) S 5 AUTOMOBILE LIABILITY - COMBINED SINGLE S ANY AUTO LIMIT ALL OWNED AUTOS BODILY j SCHEDULED AUTOS INJURY f y., (Per person) HIRED AUTOS BODILY INJURY S NON-OWNED AUTOS (Pa occident) GARAGE LIABILITY PROPERTY S DAMAGE EXCESS LIABILITY EACH AGGREF OCCURRENCE Y ti S, S OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY S (EACH ACCIDENT) Aun " � S iOfS'c'�E—�.^..UCH LI"!'T• EMPLOYERS'LIABILITY f (DISEASE—EACH EMPLOYEE OTHER y DESCRIPTION OF OPERATIONS/LOCATIONSNENICLES/BPECIAL ITEMS Town of Barnstable included as an additional insured as respects operation of swimming pool 1 A .E N.. . . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF B'A R N S T A B L E EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO BOARD OF HEALTH F MAIL_tO_DAYS WRITTEN NOTICE TO THE CERTIFICATE•HOLDER NAMED TO THE P . 0. BOX 534 LEFT; BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR H Y A N N-I,S> Ma. 02601 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE ACORD 25=_.(11/89) - PACORD CORPORATION 1989 r ; TOWN OF BARNSTABLE y fTNET�� OFFICE OF Deaa9TeDL i BOARD OF HEALTH i639' 367 MAIN STREET HYANNIS, MASS.02601 June 23, 1992 Mrs. Joanne Rice Lamb & Lion P.O. Box 511 Barnstable, MA 02630 Re: Your outside swimming pool - Old Bather Load Capacity. - 32 Outside; Modified Bather Load Capacity - 19 Capacity Dear Mrs. Rice: The Board of Health will allow you to set a maximum capacity of 19 persons at your swimming pool located at 2504 Main Street, Barnstable, MA. This includes all other persons within your pool enclosure. The following conditions must be complied with: ( 1) The pool must be supervised by a swimmer all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk, another swimmer must be provided physically present at the . pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed. ) (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed. ) (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4 ) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediatric CPR. (6) The swimming pool water must be treated for coliform bacteria at least monthly by a certified laboratory. Mrs Joanne Rice RE: Lamb & Lion Inn June 23, 1992 You are granted this modification have stated your pool previous is pusedcbyaless ity of 32 persons because you than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1992. Sincerely yours, J seph C. Snow, M.D. C airman BOARD OF HEALTH TOWN OF BARNSTABLE JCS/lls r ` i lq � 101t r 9r �� '1 Batxsttible t May 26, 1992 Town of Barnstable . Health Department Hyannis , MA.. 02601 Attention Board of Health The Lamb and Lion Inn located at 2504 Main Street `~ in Barnstable, A�MA respectfully requests a lifeguard modification JTOf Scm�� d��i''���j� y�,,n,�h�y W/ We understand all the requirements and will compli fully. Enclosed find copies of requested certificates . We hope that* we_.will-meet-_wit'n,..your criteria . R spectful y ' oa ne nd vid. Rice Innkeepers MAILING ADDRESS: Box 511, Barnstable, Mass. 02630 • 617-362-6823 r CERTIFI C___A._TE_#INSURANCE ISSUE DATE(MM/DD/YY) RODUCER 7/ 15/91 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS The Fredericks Ins . A e n C I NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, g Y nC . EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 1046 Main St. - P. O. Box 427 Ostervi 1 le , Ma . 02655-0427 COMPANIES AFFORDING COVERAGE COMPANY LETTER A The Travelers Ins . Co. COMPANY B INSURED LETTER J David J. & 3oanne Rice d/b/a COMPANY The lamb and Lion LETTER P. O. box 511 COMPANY D Barnstable , Ma . 02630 LETTER LETTER YE COVERAGES .tip / _ y:- f . 11 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE(MM/DD/YY) DATE(MM/DD/YY) ALL LIMITS IN THOUSANDS GENERAL LIABILITY (., p GENERAL AGGREGATE $2 , 000 X COMMERCIAL GENERAL LIABILITY T B D 8/ 1/91 8/ 1/9 2 PRODUCTS-COMP/OPS AGGREGATE $2 , 000 CLAIMS MADE OCCUR. PERSONAL&ADVERTISING INJURY $1 ' 000 OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $1 ' 0 O 0 i FIRE DAMAGE(Any one fire) $ 50 MEDICAL EXPENSE(Any one person) $ 5 AUTOMOBILE LIABILITY COMBINED ANY AUTO SINGLE $LIMIT ALL OWNED AUTOS BODILY SCHEDULED AUTOS INJURY $ (Per person) HIRED AUTOS BODILY NON-OWNED AUTOS INJURY $(Per accident) GARAGE LIABILITY PROPERTY $ DAMAGE EXCESS LIABILITY r EACH AGGREC-ATLH OCCURRENCE $ $ OTHER THAN UMBRELLA FORM f WORKER'S COMPENSATION STATUTORY AND $ (EACH ACCIDENT) EMPLOYERS'LIABILITY $ (DISEASE—POLICY LIMIT) $ (DISEASE—EACH EMPLOYEE OTHER { i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Town of Barnstable included as an additional insured as respects operation of swimming pool CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF B A R N S T A B L E EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO BOARD OF HEALTH MAIL-10—DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 'P. O. BOX 534 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR H Y A N N I S> M a . 02601 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AU REPRESENTATIVEREPRESENTATIVE �, v `C�_ ACORD 25-S (11/89) A C(OMR 0 PORATION 1989 9r `8atwtabte i May 26, 1992 i Town of Barnstable Health Department Hyannis , MA. 02601 Attention Board of Health The Lamb and Lion Inn located at 2504 Main Street in Barnstable, MA respectful y requests a lifeguard modification f fob We understand all the requirements and will comply fully. Enclosed find copies of requested certificates . We hope that we_wil.l .meet :with your criteria . R pectful y oanne and. vid. Rice &/ Innkeepers MAILING ADDRESS. Box 511, Barnstable, Mass. 02630 617-362-6823 i • ,'t •-° " THE *ONWE.ALTH OF MASSAGHUSETTS / ...... , �c.c .`. ..OF.................................... rP: HEALTH DEPARTMENT SWIMMING POOL INSPECTION REPORT NAME �"= ` DATE -- ADDRESS .- �., i� :'�.,� TEL. NO. OPERATOR MAX. BATHING LOAD PERMIT POSTED Regulations of the Massachusetts Sanitary Code: Article VI-"Minimum Standards for Swimming Pools". ITEMS: 1. DEFINITIONS, 2. PLAN APPROVAL, 8. SEWERAGE, 11. BATHER LOAD. 12. STRUCTURE, 14. ZONSTRUCTION, 15. JNLETS AND OUTLETS, 16. CROSS CONNECTIONS, 17. SKIMMERS, 18. DIMENSIONS, 20, WALKWAYS and 21. LADDERS. These items approved on the construction plan are of permanent nature and need not be checked at each inspection. 3. HEALTH: No employee sick, bathers take showers, clean bathing suits, sick or infected bathers not allowed, spitting prohibited, no glass or dangerous objects. Health and Shower signs posted. -/1 4. LIFEGUARDS: No unsupervised swimming. Trained lifeguards in attendance a9cording to Health Dept. ruling. 5. SAFETY: One shepards crook and one ring buoy with adequate rope for each 2000 sq. ft. water surface. 6. FIRST AID: Red Cross first aid kit (24 unit or equivalent), emergency telephone numbers posted, local -- police, state police, fire dept., and several available physicians. Telephone available (not pay station). 7. BATHHOUSE: Separate dressing and sanitary facilities for each sex, adjacent to pool, adequate, well lighted, drained, ventilated. impervious construction and light.color. One shower and one toilet per 40 bathers (min. 2 ea.), hot and cold water. soap provided, one wash bowl per 60 bathers. No common cups, towels, combs or brushes. Emergency room provided for sick or injured bathers, with cot and blanket. Foot showers (if required). Pool adequately enclosed Approved drinking water facilities. 9. CLOSURE: Operator to close pool when water does not meet the requirements of 'this code. _10. PERMIT - RECORDS: Permit posted. Written records available of daily operation of the pool, including attendance, water tests, chemicals used, hours of operation, backwashing and other information required. _13. RECIRCULATION - FILTRATION: Purification system capable of maintaining quality of water. turnover every 8 hours, Max. filtration rate 2-3 gal. per min. per sq. ft. filter. Disinfection equipment finely adjustable. _19. DEPTH MARKINGS: Marked on deck and walls at one foot intervals (shallow end) 25 ft. intervals (deep end). 22. DIVING BOARDS: Rigidly constructed, properly anchored, braced for heaviest load, sound, no splinters or cracks, non slip surface. Not over 10 ft. above water level and at least 13 ft. unobstructed head room. _23. WATER SOURCE: Water used in any swimming pool shall be from a source approved by the Health Department. 24. BACTERIOLOGICAL QUALITY: Health Dept. shall cause water samples to be analyzed as considered necessary. Quality shall meet the USPHS drinking water standards. Untreated water not over 2400 MPN Coliform. _25. CHEMICAL STANDARDS: Treated with chlorine or other effective method. Tests taken daily or more often as required by Health Dept. Chlorine residule .4 to 1.6, pH 7.0 to 7.5. 26. TESTING EQUIPMENT: Testing equipment provided, in good repair and complete with fresh reagents. i 27. WATER CLARITY: A 6 inch black disc at bottom of deepest.part of pool visable at 10 yards away. ::: 32. WADING POOLS: Quality of the water shall be the same as swimming pools. Turnover 4 hours or less. 14 as ;/ .-�'. / `i � /,i it .G•/ �?" /�y�y•s ./.� PERSON INTERVIEWED SANITARIAN FORM 1708 A. M. SULKIN, INC. 'opacity IT s PERMIT Fat. 49 THE COMMONWEALTH OF MASSACHUSETTS d� F .......TfaWX............. of .........BA13.Nx1 BARNUM........................ Board of Health �.Sri r i The Lamb and Lion Inn Thisis to Certify that ---.. ........- .....................•...........................---...................,.e.... NAME 04-Min-Street,-BarnstableA.MA.................................._..... -- ADDRESS IS HEREBY GRANTED A PERMIT To Operate a Public, Semi-Public Swimming or Wading Pool s' At ........A..qualified.swlmmer.inurt.be.at.pmol.site.all..timea.pmal.ia.opea....................:. . ..............Maethod.of-water.treatment:.iChloEine.-..AntomalticWly..fed................................... ............................................................................................................................................................................ This permit is granted in conformity with Title 2 of the Sanitary Code of The Commota wealth of Massachusetts, and expires .ember_31, 19Q1------------------------____-----------__.unleu `' sooner suspended or revokod. .....0A.11M.PshShugh•.Chair na .................. .... 1JAAR Cit..1�.aSli.................................................... BOite15; ,: .; ...............MAXI 9,................19..91. ....dt,=ph.0 -SUCtw..M.D..................................... Of d,.. ::......-r........ .... ............................................................ Heal By ................ {ln1 .................... FORM 1712 Hove$@ WARREN, INC. Aggg This certifies th JOAN RICE Lp�hH: has Wmplet f ihe'COMMYNII CPR" course of instruction f Hinertcan CAPE con C}IAPTL.R. I:ea crow rs , it Date tOurse completed° Chairman, American Nrd Cross ;;i'W �'ira CERTIFICATE AI-IN-1-S-URANCE � ISSUE DATE(MM/DD/YY) RODUCER 7/ 1 5/9 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS DOES The Fredericks ins . Agency Inc . EXTEND OR ALTER THE COVERAGE AFFORDED BY HERTIFICATE POLIICIES BELOW NOT AMEND, 1046 Main St. - P. O. Box 427 Ostervi 1 le , Ma . 02655-0427 COMPANIES AFFORDING COVERAGE I_ COMPANY.,, a ..... ..,.._._.... --i �. LETTER A The Travelers, Ins . Co. COMPANY B INSURED LETTER David J. & Joanne Rice d/b/a COMPANYC The lamb and LionLETTER P. O. box 5 1 1 LEMERNY D Barnstable , Ma . 02630 COMPANY E LETTER COVERAGES , ,_ x , 0, Iz THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ! EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE(MM/DD/YY) DATE(MM/DD/YY) ALL LIMITS IN THOUSANDS GENERAL LIABILITY p GENERAL AGGREGATE $2, 000 X COMMERCIAL GENERAL LIABILITY T B O D O/ 1/9 1 O/ 1 /9 2 PRODUCTS-COMP/OPS AGGREGATE $2 , 000 , 00O CLAIMS MADE OCCUR. PERSONAL&ADVERTISING INJURY $1 , 000 OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $1 , 000 FIRE DAMAGE(Any one fire) $ 50 MEDICAL EXPENSE(Any one person) $ 5 AUTOMOBILE LIABILITY COMBINED ANY AUTO i SINGLE $ LIMIT ALL OWNED AUTOS BODILY SCHEDULED AUTOS ` INJURY $ (Per person) HIRED AUTOS BODILY NON-OWNED AUTOS INJURY $ (Per accident) GARAGE LIABILITY PROPERTY $ DAMAGE EXCESS LIABILITY EACH AGGREC-A1 G OCCURRENCE $ $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY AND $ (EACH ACCIDENT) EMPLOYERS'LIABILITY $ (DISEASE—POLICY LIMIT) $ (DISEASE—EACH EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Town of Barnstable included as an additional insured as respects operation of swimming pool CERTIFICATE HOLDER CANCELLATION iiSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF B A R N S T A B L E EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO III B 0 A R D, 0 F HEALTH MAIL-1-0_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE j'P . O. BOX 534 I LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR HYANNIS> Ma . 02601 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE `ci_ ACORD 2 i 5 S(11/89) C A� 0 PORATION 1989 i 1 OUTDOOR POOL FEE CAPACITY: 19 PERMIT THE COMMON OF MASSACHUSET7 7�5 5 8 BAg.N STABLE..----••.......••...... TOWN............. of ................ Board of Health AND LION INN ............................................ . ................................ Tfl LAM ................... that "'••• ' to Certify •••'"""-••��� NAME TABLE '•""'�� This to ..................... BARNS •• 2504 MAIN.•STREET j.--.....N...---••-................ .. ADDRESS PERM' IS HEREBY GRANTS® p► or Jading Pool To Operate a Public, Semi-Public Swimming TIMES POOL IS OPEN R MUST BE AT POOL SITE ALL.................... ..... QUALIFIED SWIMME ....•--•-.........CHLORIN................................. —AUTOMATICALLY FED: ENT: ................... At METHOD OF .. TREATM ae of T..... . ...-- he Common- ................................WAT...................---••-........... f the Sanitary.... it with Title ° --------- unless ....................... ranted in conform Y 31s---�992------------------ This permit is g DEC�IIBI;R-- wealth of Massachusetts, and expires ed or.revoked. --•••••-'•"" Board .................... ....... ..:....... sooner suspended "•-"''•mg>4 of ....................... '�.AJ........._�..r............. Health JOSPI)�1.�lr.l�.I1dWs... J�Up,RY 1 19 9� .--5 r�•. ...... R•Gca •------------------ "� By FORM 1712 HOBBS @ WARREN. INC. MUD ` MAY 2 8 1992 __ !N r 5' r ' 4 - ENCLOSED FIND CERTIFICATE OF &IZANCE Date: ��21 /9 2 a. Insured's Name: The Lamb & Lion B & B Type of Insurance:C o m m e r c i a l We are pleased to forward the enclosed certificate of insurance on behalf of our client. If you have any further questions regarding this matter,please do not hesitate to call on us. Town of Barnstable THE FREDERICKS INSURANCE AGENCY INC. TO Board of Health P . O. Box 534 lua6 MAIN ST. -P. 0. BOX 427 pj, Hyannis , M A. 02601 OSTERVILLE, MA 02655-0427 L PHONE: (508)428-89" ISSUE DATE(MM/DD/VV) PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS The Fredericks Ins . Agency n c I NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, 9 Y Inc . EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 1046 Main St . - P. O. Box 427 Ostervi l le Ma. 02655-0427 COMPANIES AFFORDING COVERAGE I ET TERY LETTER A The Travelers Ins . Co . COMPANY B i INSURED LETTER David J . & Joanne Rice d/b/a COMPANY The lamb and Lion LETTER P. O. box 51 1 COMPANY Barnstable , Ma . 02630 LETTER D i COMPANY E LETTER' COVERAGES --r "� •� 77 THIS IS TO CERTIFY THAT.THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED;ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT'WITH RESPECT TO WHICH THIS CERTIFICATE MAY'BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED'13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO 5'iPE OF iMSIiRANGE I POLrCY EFFECTIVE POLICY EXPIRATION LTR Jc r t."ii'vl�oir+ DATE(MM/DDIYY) DATE(MM/DD/YY) I .GENERAL LIABILITY, GENERAL AGGREGATE $2 , 000 X COMMERCIAL GENERAL LIABILITY• d 8/ 1/9)� B/ 1 9 3 PRODUCTS-COMP/OPS AGGREGATE S 2 000 CLAIMS MADE OCCUR. 16 B O—2 2 51.K 1 2 5—3 PERSONAL 8 ADVERTISING INJURY S 1 r 000 OWNER'S 6 CONTRACTOR'S PROT.: C O F—9 2 EACH OCCURRENCE 5 1 000 FIRE DAMAGE(Any one lire) S so , MEDICAL EXPENSE(Any one person) S AUTOMOBILE LIABILITY COMBINED 5 j SINGLE $ i ANY AUTO LIMIT i ALL OWNED AUTOS BODILY y INJURY $ ' SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per.accident) i i GARAGE LIABILITY PROPERTY`DAMAGE S II J EXCESS LIABILITY EACH AGGRE(::.. f OCCURRENCE I S S OTHER THAN UMBRELLA FORM STATUTORY WORKER'S COMPENSATION i . $ (EACH ACCIDENT) i AND S (DISEASE—POLICY LIMIT) EMPLOYERS'LIABILITY , S (DISEASE—EACH EMPLOVEEI OTHER r " DESCRIPTION OF OPERATIONS/LOCATIONSNENICLESISPECI AL ITEMS Town of Barnstable included as an additional insured as respects operation of swimming pool SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF B A R N S T A B L E EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO i BOARD OF HEALTH MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE P. Q. BOX 534 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR H Y.A N N I S> M a . 02601 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 28=S (11/89j ' (C)ACORD CORPORATION 1989 j } , • y�TN[T�` The n of Barnstable I Health Department { "M'TAn 367 Main Street, Hyannis, MA 02601 ru• y Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 Director of Public Health April 4, 1991 Mrs. Joanne Rice Lamb & Lion P. O. Box 511 } Barnstable, MA 02630 Re: Your outside swimming pool - Old Bather Load Capacity - 32 Modified Bather Load Capacity - 19 Dear Mr. Rice: We will allow you to set a maximum capacity of 19 persons at your swimming pool located at 2504 Main Street, Barnstable, Ma. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form Is enclosed). (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The whirlpool water must be tested for coliform bacteria at least monthly and pseudomonas bacteria at least once every two months by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediatric CPR. (7) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. i Mrs. Joanne Rice/Lamb & Lion I� April 4, 1991 0 You are granted this modification of your present pool capacity of 32 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1991. Sincerely ours, Ge7 AAAA- Ann Jane shbaugh Chairman BOARD OF HEALTH TOWN OF BARNSTABLE AJE/bcs Enclosure I, Ali Batastable i March 22 , 1991 Thomas A.:,,McKean Director of Public Health The Town of Barnstable Health Dept . Hyannis , MA. 02601 Att : Ann Jane Eshbaugh James H. Crocker, Sr . In accordance with your instruction The Lamb and Lion Inn located at 2504 Main Street in Barnstable, MA. requests a modification from requiring a fully certified lifeguard in attendance at all times . We are a very small inn and have a semi-public pool located within the confines of our building. We never have more than 19 people . Inclosed is a phot-copy of Joan (Joanne). Rice certificate of completion in Community CPR. Course completed on February 27, 1991 . She will serve as our certified swimmer also . This modification was ,-allowed last year by the board . spectfully sub ed , oanne and David Rice Innkeepers MAILING ADDRESS: Box 511, Barnstable, Mass. 02630 • 617-362-6823 4 ISSUE DATE(MM/DD/YY) CERTIFICATE'. INSURANCE 4/2/91 PRODUCER z THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, I EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW HART INSURANCE AGENCY P.O. BOX L COMPANIES AFFORDING COVERAGE BUZZARDS BAY . MA 02532 COMPANY A LETTER WARNER INSURANCE CO CODE SUB-CODE rr COMPANY B INSURED € LETTER DAVID J & JOANNE RICE D/B/A i .CO MPRNY C THE LAMB AND LION P.O. BOX 511 i COMPANY LETTER D BARNSTABLE MA 02630 € COMPANY E LETTER COVERAGES: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Col 'POLICY EFFECTIVE'POLICY EXPIRATION} LTR TYPE OF INSURANCE POLICY NUMBER ! DATE(MM/DD/YY) DATE(MM/DD/YY) # ALL LIMITS IN THOUSANDS € ! 111 1.NGENERAL LIABILITY 1 i GENERAL AGGREGATE $ 2,000 X i COMMERCIAL GENERAL LIABILITY ' € ' ~—F F PRODUCTS-COMP/OPS AGGREGATE!$ 1 OOO ^�CLAIMS MADE X!OCCUR.! WXM2461 381 j 8/1/-90 3 8/1/91 PERSONAL&ADVERTISIN.G INJURY j$ OWNER'S&CONTRACTOR'S PROT. j �H OCCURRENCE M is 1 ,000 1 FIRE DAMAGE(Any one fire) !$ !MEDICAL.EXPENSE(Any one person) AUTOMOBILE LIABILITY # 1 COMBINED % I-"-- € SINGLE $ € )ANY AUTO LIMIT i I ALL OWNED AUTOS j BODILY I SCHEDULED AUTOS INJURY i$(Per person) I '!HIRED AUTOS 1 BODILY NON-OWNED AUTOS ! INJURY $ i I 3(Per accident) GARAGE LIABILITY ; PROPERTY DAMAGE i$ I EXCESS LIABILITY ! i EACH _ AGGREGATE OCCURRENCE' ! $ $ OTHER THAN UMBRELLA FORM ! WORKER'S COMPENSATION � — STATUTORY x AND ! $ (EACH ACCIDENT) —-----t_—•._ $ i (DISEASE—POLICY LIMIT) EMPLOYERS'LIABILITY -- € $ € (DISEASE—EACH EMPLOYEE) !OTHER __ 1 € i € 3� r - 3 ! DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS TOWN OF BARNSTABLEyINCGUDED AS AN ADDITIONAL INSURED AS RESPECTS OPERATION OF SWIMMING POOL CERTIFICATE HOLDER y CAN-CEILATI�ON y y � g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF BARNSTABLE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO BOARD OF HEALTH 5 MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE P.O. BOX 534 LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR HYANNIS MA 02601 LiABILI ANY KIND UPO E MPANY,ITS AGENTS OR REPRESENTATIVES. A HO 7 EP AT y it �o ACORD;25-S(3/88) CORPORATION;1988 ' r NOTE: Training in Community Cardiopulmonary Resuscitation (CPR)is valid for one year from the course completion date. Name of Chapter CAPE COD CHAPTEV Chapter Representative Instructor Holder's Signature — 42 Cert.3213(Mac1988) This certifies that JnAN RT( P, Ti completedd the'COMMUNITY^�G'i'i� 3 course of instruction A American HYANNIS `AMA.. Red Cross FEB' '2 7 19911 - d ti Date course completed Chairman,American Red Cross J ssou/,�Pau ut:auaury'ueuutey:) ' pajajdwo:) asinoz) aleQ ; t a Pau t: t .,d treouawy uor>3"Sul jo as na) A LINR14iW0�..a1{1„palaldwo�,suq 6" 1 , NOTE: Training in Community Cardiopulmonary Resuscitation (CPR)is valid for one year from the course completion date. Name of Chapter PTER Chapter Representative Instructor. Holder's Signature 42 Cert. 3213(Mar.1988) TOWN OF BARNSTABLE re�'P� ♦� OFFICE OF DAUSTA33L s BOARD OF HEALTH NABS p� 00 1639. � 367 MAIN STREET 'Ea MAY k' HYANNIS, MASS.02601 May 15, 1990 Mrs. Joanne Rice Lamb & Lion P. O. Box 511 Barnstable, MA 02630 Re: Your inside swimming pool - Old Bather Load Capacity - 32 - Modified Bather Load Capacity - 19 Dear Mrs. Rice: We will allow you to set a maximum capacity of 19 persons at your swimming pool located at 2504 Main Street, Barnstable, Ma. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, eighteen (18) years of age, or older, qualified by you at the pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be certified in adult, child, and pediatric CPR by the American Red Cross, American Heart Association or equivalent, be familiar with lifesaving equipment and knowledgeable in first aid procedures including resuscitation. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed). (3) We must have a copy of your current insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. (6) The swimmer(s) must hold a current American Heart Association, American Red Cross, or equivalent CPR certificate with training in adult, child, and pediatric CPR. You are granted this modification of your present pool capacity of 32 persons because you have stated your pool is used by less than 19 persons. L_ _ Mrs. Joanne Rice Re: Lamb & Lion May 15, 1990 Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will be required to cease operation of the pool. This modification expires December 31, 1990. L Very t my you s, Grover C. M. Farrish, M.D. Chairman BOARD OF HEALTH TOWN OF BARNSTABLE GF/bs Enclosure o,THET TOWN OF BARNSTABLE OFFICE OF B MAE&E& s BOARD OF HEALTH � pp t6;q. 6� aMAi 367 MAIN STREET HYANNIS, MASS. 02601 May 30, 1989 Mrs. Joanne Rice Lamb & Lion P. O. Box 511 Barnstable, Ma 02630 Re: Your outside swimming pool - Old Bather Load Capacity. - 32 Modified Bather Load Capacity - 19 Dear Mrs. Rice: We will allow you to set a maximum capacity of 19 persons at your swimming pool located at 2504 Main Street, Barnstable, Ma. This includes persons in your pool and includes all other persons within your pool enclosure. The following conditions must be complied with: (1) The pool must be supervised by a swimmer, eighteen (18) years of age, or older, qualified by you at pool site at all times the pool is open. We wish to make it clear that this swimmer must be at the pool and cannot be observing from the desk. If your swimmer is temporarily assigned duties at the front desk, another swimmer must be provided physically present at the pool. This swimmer must be familiar with lifesaving equipment and knowledgeable in first aid procedures including resuscitation. (Minimum swimmer qualification requirements are enclosed). (2) You must keep a permanent record on a form prescribed by the Board of Health listing each swimmer supervising the pool when it is in use. (Sample of prescribed form is enclosed.) (3) We must have a copy of your insurance policy naming the Town as coinsured in the amount of $1,000,000. (4) All other regulations contained in 310 CMR 12.00, Minimum Standards for Swimming Pools, must be strictly complied with. (5) In the event your pool is used by persons other than registered motel guests, or persons charged a fee, it is your responsibility to provide a lifeguard with a current Red Cross Senior Life Saver's Certification or a National Y.M.C.A. Senior Life Saver's Certificate. (6) The swimming pool water must be tested for coliform bacteria at least monthly by a certified laboratory. Mrs. Joanne Rice e Re: Lamb & Lion May 30, 1989 • You are granted this modification of your present pool capacity of 32 persons because you have stated your pool is used by less than 19 persons at all times. Please be advised that if you exceed this capacity of 19 persons, your modification will be invalid and you will revert to your measured bather load capacity of 32 persons. A certified lifeguard will then be required. The Board also reserves the right to require a certified lifeguard if violations of 310 CMR 12.00, Minimum Standards for Swimming Pools, are observed. This modification expires December 31, 1989. Very truly yours, Grover C. M. Farrish, M.D. Chairman BOARD OF.HEALTH TOWN OF BARNSTABLE GF/bs Enclosure 0"'Q Jane Eshbaugh, Acting Cha Ides tVK Ali Bakwtdble i May 22 , 1989 Town of Barnstable Board of Health South St . Hyannis, Ma . , 02601 Attn: Ms . Barbars Sullivan Dear Ms'. Sullivan, We hereby request a modification to our pool for under 19 people without a lifeguard for our new license at the Lamb & Lion Inn, 2504 Main St . , Barnstable, Ma . , 02630. Thank you for your attention to the above. Cordially yours, LAMB & LI �NN �A _. 1`Joanne & Dav`ic Rice c Innkeepers MAILING ADDRESS: Box 511, Barnstable, Mass. 02630 . 617-362-6823 0 o a Q o 0 gord I aiouumu*p maumajISSUE DATE(MM/DD/YY) ® 5/19/89 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS F Bryden Insurance Agency NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, 6 Willow Street EXTEND OR ALTER THE COVERAGE AFFORDED'BY THE POLICIES BELOW. Sandwich, MA 02563 COMPANIES AFFORDING COVERAGE COMPALETTER A Bankers Standard Ins. Co. COMPANY INSURED LETTER B David and Joanne Rice d/b/a The Lamb & Lion LETTER COMPANY C 2504 Main Street Barnstable, MA 02630 LETTERNY D arn COMPANY B LETTER • THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS,AND CONDI- TIONS OF SUCH POLICIES. CO POLICY EFFECTIVE POLICY EXPIRATION LIABILITY LIMITS IN THOUSANDS LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDNY) DATE(MWDDNY) EACH OCCURRENCE AGGREGATE GENERAL LIABILITY BODILY A X COMPREHENSIVE FORM SVP D15893990 6/l/89 6/1/90 INJURY $ $ PREMISES/OPERATIONS PROPERTY UNDERGROUND DAMAGE EXPLOSION&COLLAPSE HAZARD $ $ PRODUCTS/COMPLETED OPERATIONS CONTRACTUAL COMBINED $1,000. $11 OOO. INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE - i PERSONAL INJURY PERSONAL INJURY $ si AUTOMOBILE LIABILITY BODILY INJUANY AUTO (PER P (PER PERSON $ ALL OWNED AUTOS(PRIV. PASS.) BODILY INJUALL OWNED AUTOS(OTHER THAN) (PER ACgDEMf) $ `PRIV. PASS. PER HIRED AUTOS PROPERTY NON-OWNED AUTOS DAMAGE $ GARAGE LIABILITY 81&PD COMBINED $ . H EXCESS LIABILITY i UMBRELLA FORM BI&PD COMBINED $ $ OTHER THAN UMBRELLA FORM WORKERS'COMPENSATION STATUTORY AND v $ (EACH ACCIDENT) $ (DISEASE-POLICY LIMIT) EMPLOYERS'LIABILITY $ (DISEASE-EACH EMPLOYEE) OTHER i - f DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Additional Named Insured - Town of-Barnstable for pool liability Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX- PIRATION DATE THEREOF, 'THE ISSUING COMPANY WILL ENDEAVOR TO a MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 367 Main Street LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Y Hyannis, MA 02601 OF ANY KIND UPON T OMPANY, ITS A ENTS OR REPRESENTATIVES. AUTHORIZ EP E IVE it 5/19/89 •' ' Bryden Insurance Agency •'• •"•' SQ7;1 .I f aa y 249-011 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...__-_.. .. OF.-- Yn1 ................ Appliratiou for %gpwiai Work,5 Tatuitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (L}- an Individual Sewage Disposal System at: 11 a .......... 61VU lLcLL�/l�lll.... ... ............ 1"..._........ - dr .. -- Lot NLocat o . ----........_. ess ---_______-_--_-_------ Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures .•___________________________•-- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.._...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .........._.................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ 0 Nature of epairs or Alterations—Answer when applicable._____1-"�10V__ �..�.._.__. W,/ _ _____________•-- 7. -,� � �� � Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI E 5 of the State Sanitary Code— The undersigned further agr es not to place the system in operation until a Certificate of Compliance ha/been ssued by theboa f health. Signe � ••-•-•. cDateApplication Approved By•--•-•- = ;- r---_____---•••................... ---•`�-- 42.. �'�---_... Date Application Disapproved for the following reasons_................................................................................................................ ......-•-•__________________________•-••_..._-_._______.••••-..._••----•---------•--••••-____._---_.._.....-----------•-•--________________-______-•-•--•-•-•-•--•---•-•••-----•----_________-••--•------ Date PermitNo......................................................... Issued....................................................... Date QQ L1 No.......�1 ..._: .`f~4f FEB........ _............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �..f._.- _'. OF......... i i' t ;���1 Appltratilau for Disposal Works Towitrurtiuu truti# Application is hereby made for a Permit to Construct ( ) or Repair ( i-) an Individual Sewage Disposal System at: 1 p J. . •i fr- r ...............__......_.....................---•--------•-----..........._-----•......•...... ....................•-•--•---••---•-------•--••---•----......------..........................••... Location-Address �f or Lot N .( ......................__................•.. o. / �::/3 > �' , .1f............• ---_......._................ ...........................................`....................................................... 2-} Owner i Address �jj/.............. ................................................ ------.. ..'..... :_.i_/_//.. ------•--------------------------------------••--• Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. -of persons............................ Showers — Cafeteria P4 Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) . - `4 Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------- (-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P -----------------------------------•----..:----------------------- ------- ........................................................................ 0 Description of Soil........................................................................................................................................................................ x. �., r........................................ x - = -----------•--------------------•---------------------------------------•-----•----------•---•-------•--•--•-•--•-•---.....-- V Nature o Repairs or Alterations—Answer when applicable.______`__ ,/_%_.........!.....::.........!...__f% ...........................__. ...... , rZ � / j/%. / ij 1- C -----•--••-------•---------------------•-----••••-•••--•-•••••-•-----•-•-- ••-•-••-••-•..._.............•-•••• •-••...........--.......................................... Agreement: ` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been/issued by the board,of health. J Signed. ..r`. rx... ' - = `Date Application Approved By.......... : = �� ................................. -..fir.... ...`�----------- Date Application Disapproved for the following reasons:................................................................................................................. ..•-•-•---•-••••••••......---••-•••...............................••••--•-•----•-•--------••--•-•--•....-••---•-••••-...•------••••--••-•--•-------••=•-••-•••-•-•--•---......••-•-•--•-•-•--••--••---. Date PermitNo......................................................... Issued.................................................. Date THE COMMONWEALTH OF MASSACHUSETTS J BOARD OF HEALTH f �rr ifrttle of (�nrutliure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or. Repairedby ( ) .....------- - ........................ •-•----•--•---•-•------•----•--------•..........................................•-•---•-••------------ Installer , ---•- f! - - i r� has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__- --?-':___:-r ............ dated________________________ - THE ISSUAPICE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUARANTEE THAT THE SYSTEM WIL FU TION SATISFACTORY. DATE.. - .................................................. Inspector.. ------------------------------------------------- ........ THE ... COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , �...........................OF.....-.:.!..r / J / .-!f J/ C r y ............... ........................................:.._........ N FEE........................ Permission is hereby granted--------- .........I_-_.fit. ... .......r-___�............... !_ to Construct ( ) or Repair an Individual Sewage Disposal System at No.._•_..../ '...... ....... . =r 1 f•--i//_.._'.:....:............_..__._... !- `// /%. - /"I//A " /Ic......Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... DATE 1 S Z 47 Board of Health -----••••• .••-••-••-•....••••....--•------••----•-•-- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS �� �u 3. 2013 3:CUM k 0879 P. 7 ENVIROTECHLABOR,4TORTES,INC. ILIA CERT.NO.:M-MA 063 8 Jon Sebastian Drive Chit 12 Swulwlch,MA 02563 (508)888-6460 1-800-3394460 PAX(SOS)888-6446 Client x4me Lamb&Zion Location Bamalabfe,MA Address ATTN:Allce PO Box 0511 Bamstable 02630 Sample bate 00/27/13 Collected By Client Sample Time NA Sample Type Swimming water bate Received '06127/13 Lab Order Number PS-130548 zocp[lore Source 7p to CollLl d .. 7Yttte CollQcted : . ' : Comments Analysis Regiuested antis Recommended Linuts Analysis lr U11 Metl+ad jDateArialyzed Atenlyted By Total Coflfoall 1100 ml 2 0 92226 6/27/2013 RS Standard Plate Count 11 ml 200 NIT 9215 B W27/2 Peeudomonas Aeruginoss /100 all 1 NT 9213 E 6/27/2013 RS Contmertts: Yes-Water is suitable for swimming for ometeM tested. -- ---- - . ..---- .. ..._._.._bate — .. ------- Rot Id J.Son Loborarowy D" iar BRL—Below Reportable Limits Page 1 of 1 OSee Adoehed I SYSTEM DESIGN: SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES LEGEND GARBAGE DISPOSER IS NOT ALLOWED NOT TO S MARKED WITH MAGNETIC TAPE OR ° COMPARABLE MEANS FOR FUTURE LOCATION. APPROX. NGVD RPOVIDE WATERTIGHT MIN. 20" DIAM. SCALE) 1. DATUM IS 99- EXISTING CONTOUR ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE.COVERS TO WITHIN 3" GRADE a DESIGN FLOW: 10 BEDROOMS 0 110 GPD = 1100 GPD 2" PEASTONE OR GEoTExnLE 2. MUNICIPAL WATER IS EXISTING o Cb X 99.1 EXIST. SPOT ELEV. \ TOP FOUND. FILTER FABRIC OVER STONE USE A 1100 GPD DESIGN FLOW " 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. 47.0' MINIMUM .75' OF COVER OVER PRECAST 2x SLOPE REQUIRED OVER SYSTEM 44.0' -45.0'� 99 PROPOSED CONTOUR w (98.4� PROPOSED SPOT EL. SEPTIC TANK: 1100 GPD (2) = 2200 PRECAST H-10 DB-6 BLOCKS OR 2,Q 4. DESIGN `LOADING FOR SEPTIC TANK , . TO BE AASHO H- USE A 4000 GAL. DUAL COMPARTMENT H-20 SEPTIC TANK RISERS (TYP.) PRECAST RISERS 2's 4"0SCH40 PVC MORTAR ALL H_10 DESIGN LOADING FOR OTHER PROPOSED PRECAST UNITS 11 C_ TH1 PIPES LEVEL 1ST 2' �4, COMPONENTS ' TO BE AASHO H-1Q Locus TEST HOLE to' ) . • 42.0 YYY LEACHING: ENDs SIDES 20' . ., •= 5. PIPE JOINTS TO BE MADE WATERTIGHT. 2% SLOPE of cRouNo SIDES 2 59 + 11.8 2 (.60) = 170 GPD x 2 = 340 GPD TEE r ,ovo�oJo,• ° ° ° of TEE , ° ° ° ° � ° ° S D ( ) 44.25 u A�iPARTMEr GAL r 20 44.0' ° ° > 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH BOTTOM 59 x 11.8 (.60) = 417.7 GPD x 2 = 835 GPD ° 41.17- °°°°°°°° ®®®®®®®®®® ®®�®®®®®®®® SEPTIC TANK o °o°°0000$oo°° °o° °o°o°o° o°o°o°00 310 CMR 15.000 (TITLE 5.) o0 5' 7• LW. LEVEL GAS BAFFLE :.: °o a00000000000 oQ ;°°°°°°°°°°°O ®®®®®®®®®®® ®®®®®®®®®®® °°o°°o°°o°°o CCape Cod ommunity �Q3 UTILITY POLE SHOREY OR Ep "O"O"O"O"O"O °^ 100000oao ®®®®®®®®®® ®®®®®®®®®®® ,•;�o�o�o�o 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o LEACH PIT/CESSPOOL TOTAL: 1958 S.F. 1175 GPD SEE DETAIL BELOW 41.94 41.771000090 ° College °,: . O ° °°°°°°°° 39.17 ,.. :. ; 6" MIN SUMP BE USED FOR LOT LINE STAKING OR ANY OTHER 9 NOTE. NOT ALL SYMBOLS MAY APPEAR IN DRAWING O O O O O O O O O O O' C 12" MIN. TNT. DIM. L PURPOSE. ( ) o 0 0 0 0 0 0 0 0 0 0 0 3/4 1-1/2" DOUBLE WASHED STONE H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL USE 2 SYSTEMS OF 6 EACH 500 GAL. LEACHING CHAMBERS ACME OR EQUAL 000000o0o000000o0oc " ' 1Or%O"O`%0"Or" r ALL BOUND PRECAST STRUCTURES (12) UNITS REQUIRED 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. o Route 6 WITH 4 STONE AT ENDS AND 3.5 AT SIDES 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 59.0' X 11.83' (x 2) i� 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED COMPACTION. (15.221 [21) � WITHOUT INSPECTION BY BOARD OF HEALTH AND *THE INSTALLER SHALL VERIFY THE 2 - PERMISSION OBTAINED FROM BOARD OF HEALTH. LOCUS MAP LOCATIONS OF ALL UTILITIES AND ALL ( x SLOPE) ( MIN SLOPE) ( 1 X SLOPE) BUILDING SEWER OUTLETS AND MA �' MIN. 1a CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING NOT TO SCALE APPROVED DATE BOARD OF HEALTH FOUNDATION 10 SEPTIC TANK 60 D' BOX 62' LEACHING 28.0' BOTTOM TH-1 DIGSAFE (1 888-344-7233) AND VERIFYING THE ELEVATIONS PRIOR TO INSTALLING ANY FACILITY NO GROUNDWATER FOUND LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PORTION OF SEPTIC SYSTEM (MAX) PRIOR TO COMMENCEMENT OF WORK. ASSESSORS MAP 257 PARCEL 3 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 13. ENGINEER TO-INSPECT AND CERTIFY REMOVAL AND INSTALLATION. 362.37' A,�^ H-20 CAST IRON COVERS ,v,^��" EQ" PROVIDE APPROX. 28' OF 40 MIL P� LINER AT LIMIT OF ,5' REMOVAL IN AREA SHOWN. TOP AT EL. 42.0', �e S + 6 BOTTOM AT EL. 38.0't 5' REMOVAL OF UNSUITABLE SOIL REQUIRED ENGINEER TO X 16 AROUND PERIMETER OF LEACHING FACILITY, " INSPECT AND �1 DOWN TO SUITABLE SOIL LAYER. REPLACE 4 OSCH40 PVC 1 CERTIFY I WITH CLEAN MED. SAND, TO MEET S=1 7 MIN. E ►M 1n ` ) x 32.3 SPECIFICATIONS OF 310 CMR 15.255(3) i / 7.64 TEST HOLE LOGS 44.25 0" 20„ 44.0 C �I 3 a / 47.63 4"�SCH40 PVC ]::�j 20" 44.08' t l �i c X 39. 4 __j V S=1� MIN. ^�4' \ " V ARNE H. OJALA, PE, SE 2500 GAL l a'� �� �� I 23 COMPARTMENT 20" TEE 1377 " ( .96 GALLON 19 TEE W/ GAS BAFFLE W GAS BAFFLE ' - -- - DAVID W. STANTON, IRS COMPARTMENT / 48.24 WITNESS: 10.0 5.5 k�S 97 spa- - 5o GRAVEL 48.29 DATE: 3/28/11 8 0 48 61 PARKING PERC. RATE = < 10 MIN/INCH l oqa�°0,0q 6" BAFFLE `� 14 �r � _ I a\ \\ CLASS � SOILS P# 13217 MECHANICAL COMPACTION & 6" STONE (TYP.) 310 CMR 15.228(1) LOT AREA ti --- --- �- _ 2.25 AC x 45.61 F(V y, .08 k� <� \ 49.03 49 O w 5.53 46.2 gg \ G 4$'98.87 ELEV. ELEV. 4000 GAL H-20 ST- SHOREY 7X 17 OR APPROVED EQUAL x 4 .66 "' �5' 6.28 R� k \.g: �� z5 N „ Q 46.0' " 45.0 �4 /1r1 \ 47.72 Q 4 .37 J X4 .zX 8 ter`; �t `��}� �� �Ix 9.'4,7 / QP \\ FLLLLr UNSUIT. A X 41 5 /�� x 6 I 44.88\ ({ f{r 47 4 / � \ 47.89 6 �SL UNSUIT. 42.981 \ JK / x 46. �� 7 4 / ^'S.OQ �...:. / d LP 4419 x i149.52 ` \48.26 _ B I`43.30 I .02 _ - 48.05 BOULDERS & ,C1 UNSUIT. X 7 ^� �,i 4-4$743 DECK /SL SILT LOAM 0 F?ROP. 1 42. 3.1 10YR 5/4 „ 10YR 5/6 , N I L�P4 Ex. \ STONES T UNSUIT. �� STONES rn EXIST. LEACH �, o J , I O I� DBOX �'� 4000 �a° METER 36 42.0 2 EXIST. X 4 55' PITS/CESSPOOLS (TYP I GAL. ST SEE NOTE 12. 41.9s Y\43.51 2S. 11 000 \\ �� 11 2.24 . 144," 34.0' \ I S 47. X 46.29 ( � EXISTING C BUILDING a 5' REMOVAL OF UNSUITABLE SOIL REQUIRED -y� I k 4 7 VIC I d 4 �J, C2 AROUND PERIMETER OF LEACHING FACILITY 7.32 �` `,• SL (DOWN APPROX. 12' SEE TH 1), I •2 SL SUITABLE SOIL LAYER. REPLACE WITH CLEAN X 45.48 \ 4.4 2^ / �G'I' �y PERC MED. SAND, TO MEET SPECIFICATIONS OF 310 445.3s \/ I EXISTING �' 168" 10YR 5/6 14.0' O 72" 10YR 5/6 CMR 15.255(3) -j' x 58.53 I BENCHMARK 5.34 BUILDING 4- TOP OF BOTTOM STEP „-4 BOG C3 ELEV. 48.6' \ 9 MS \ 216" 2.5Y 7/4 28.0' 192" 29.0' NO GROUNDWATER ENCOUNTERED I + TITLE 5 SITE PLAN LAMB AND LION OF B&B 50.27 2504 ROUTE 6A BARNSTABLE 50..79 �S .go, �, PREPARED FOR 167 s ELEc. GAS X41.87 LAMB & LION INN METER METE f EXIST. 4 BR. LLC SEPTIC SYSTEM / X 41.E THIS AREA (TO / REMAIN) MARCH 29, 2011 / 1.99 Scale: 1"= 20' / P/ 6 / 0 10 20 30 40 50 FEET LOT AREA: 96,958 SF / w � ! ` 1 / �/ O OF --_ off 508-362-4541 MIS s9c O �p. gs9c y�HOFMgs H°FMq sq fax 508-362-9880 DANIE ti� �o DA L yam �� sgoy q�� downcape.com A. N� o A. �° DANII3LA. �N �� DANI�L JA �.74 '�/ P �' OJALA � " OJALA OJALA 'o OCIVI� D ' cape engineefing, MC. No.40980 CIVIL No.4650 / G N .40 0 po NO.46502 A Clvil engineers ly�o ssv � q v �fi sT k' FSSGONAL �� w land surveyors ALE 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT. MA 02675 045