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FROM PHONE NO. MAY. 08 1997 08:51AM P2
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Frank Reinhardt
P.O . Box 573
Hyannisport , MA 02647
Phone/Fax : 508-563-5210
May 8 , 1997
Christine Kutchinski
Barnstable Board of Health
Barnstable , MA 02630
Fax : 508-775-3344
Dear Chris ,
Enclosed are three letters , one dated 03-26-97 from
the Occupational Safety and Health Administration (OSHA)
to the Center for Preventive Medicine , another dated
03-31 -97 from the Center for Preventive Medicine back to
OSHA , and the third , a letter dated 05-07-97 from myself
to OSHA.
I believe. that these three letters portray the char-
acter and integrity of Dr . Michael Janson and Kim Allen , P.A .
The Board of Health investigated 275 Mill Way , Barnstable,
MA after OSHA had sent them a letter of alleged complaints .
I believe your investigation found that nothing had changed
since OSHA ' s complaint letter . If you feel that these
letters are significant , please pass them on to the state
agency investigating the Center for Preventive Medicine .
For future reference, could you please inform me of the
name of the state agency?
Please feel free to call me with any questions and
thank you for your cooperation in this matter .
Sincerely ,
Frank Reinhardt
FROM PHONE NO. MAY. 08 1997 08:52AM P3
U.S. Department of Lab.
Occupational Safety and Health Administration
639 Granite Street -4th Floor
Braintree, MA 02184 ''•
Phone: (617) 565-6924 Fax: (617) 565-6923
Reply to the attention of:
03/26/97 Complaint #200455244
I.H. Supervisor
(617) 565-6924
The Center for Preventative Medicine
Dr. Michael Janson
P.O. Box 732
Barnstable, MA 02630
Dear Dr. Janson:
On March-26, 1947, the Occupational Safety and Health Administration (OSHA) received a
notice of health hazards at your worksite at:
274 Millway Road
Barnstable, MA 02630
We notified you, by telephone, of these alleged hazards on March 26, 1997. The specific nature
of the alleged hazards is as follows:
1) IV's are being started in a room with carpeting, carpeting is not an easily cleanable
surface int he event of a blood or other body fluid spill.
2) IV's.are being started without a sharps container nearby.
3) IV's are being started with the patients arm on a pillow. Potentially contaminated
pillows are being reused on patients.
4) IV tubing contaminated with blood is being disposed of in the regular trash.
5) 'There is no eye wash in the office.
6) Staff members eat their lunch in the laboratory where blood and urine are collected and
tested.
We have not determined whether the hazards, as alleged, exist at your workplace; and we do
not intend to conduct an inspection at this time. However, since allegations of violations and/or
hazards have been made, we request that you immediately investigate the alleged conditions and
make any necessary corrections or modifications. Please advise me in writing, no later than
April 2, 1997, of the results of your investigation.
FROM : PHONE NO. MAY. 08 1997 08:52AM P4
You must provide supporting documentation of your findings, including any measurements or
monitoring results, and photographs/video, and a description of any corrective action you have
taken or are in the process of taking. Please fax us your response if possible, addressed to the
name in the letterhead, at (617) 565-6923.
This letter is not a citation or a notification, of proposed penalty which, according to the OSH
Act, may be issued only after an inspection or investigation of the workplace has been
conducted. It is our goal to assure that hazards are promptly identified and eliminated. please
take immediate corrective action where needed. We encourage employee participation in
investigating and responding to any alleged hazard. If we do not receive a response from you
by April 2, 19971
indicating what appropriate action has been taken or that no hazard
exists and why, an OSHA inspection will be conducted.
An- inspection may include a review of the following: injury and illness records, hazard
communication, personal protective equipment, emergency action or response, bloodborne
pathogens, confined space entry, lockout, and related safety and health issues.
Please note, however that OSHA selects for inspection some cases where we have received
letters in which employers have indicated satisfactory corrective action. This is to ensure that
employers have actually taken the action stated in their letters.
The State of Massachusetts offers OSHA consultation services, without charge, to assist in
resolving all occupational safety and health issues. The variety of services available or the
scheduling of those services may be limited by the consultation projects requirement to give
priority to small businesses in high hazard industries and by its backlog. However, you may
be able to obtain similar services from your insurance carrier or private consultant in a more
timely fashion. To discuss or request the services, call or write your consultation project at the
following address:
Mr. Joseph LaMalva, 7(c)(1) Project Manager
The Commonwealth of Massachusetts
Department of Labor and Industries
1001 Watertown Street
West Newton, MA 02165
(617) 727-3982 FAX: (617) 727-4581
You are requested to post a copy of this letter and your response to it where it will be
readily accessible for review by all of your employees and return a copy of the signed
Certificate of Posting (Attachment A) to this office. In addition, you are requested to provide
a copy of this letter and your response to it to a representative of any recognized employee union
or safety committee if these are at your facility_ Failure to do this may result in an on-site
inspection.
2
FROM PHONE NO. MAY. 08 1997 08:53PM P5
The complainant has been furnished a copy of this letter and will be advised of your response.
Section 11(c) of the OSH Act provides protection for employees against discrimination because
of their involvement in protected safety and health related activity.
If you have any questions concerning this matter, please contact the Area Office at 639 Granite
Street, 4th Floor, Braintree, MA 02184. Your personal support and interest in the safety and
health of your employees is appreciated.
Sincerely,
&ally
Brenda J. Gordon
Area Director
Enclosure
"Attachment A"
3
FROM : PHONE NO. MAY. 08 1997 08:54AM P6
C0968
"Attachment A"
CERTIFICATE OF POSTING
OSHA NOTIFICATION OF ALLEGED HAZARD(S)
The Center for Preventative Medicine
Complaint #200455244
Date of Posting:
Date Copy Given to an
Employee Representative:
On behalf of the employer, I certify that a copy of the complaint letter received from the
Occupational Safety and Health Administration (OSHA) has been posted, and the employer's
response to OSHA, will be posted in a conspicuous place, where all affected employees will
have notice, or near such location where the alleged violation occurred, and such notice has been
given to each authorized representative of affected employees, if any. This notice was or will
be posted for a minimum of ten (10) working days or until any hazardous conditions found are
corrected.
Signature
Title
4
FROM : PHONE NO. MAY. 08 1997 08:54AM P7
APR -O?-97 07 :44 FROM: U-S , D.O .L . OSHA . SOUTH TD:
01/01/1995 06:56 5083521525 MIOIAE JAKu UN my _ PAGE 2/4
Center for Preventive Medicine r
11�itcitaet Janson,MD
Kim Allen,pia►-C
Uz YOU,PA-C
March 31,1997
U.S.Dept of Labor
OSHA
639 Granite St-4th floor _
Braintree, MA 02184
Attention of complaint 9200455244
I.H. Supmjwr:
In regards to the eoampkint feed to us on March 27, 1997:
1) It's are started in our laboratory which has a lineleum floor: Please see
photograph provided for previous complaint##200453579.
2) Please see photographs provided fos previ0Us complaint#200453579.
Those photographs clearly depict our sharps contai.Qers, as well as the
close proximity to the phlebotomy chair.
3) Ar s are not started with the puticufs arm on a pillow. The IV is started
in the laboratory at the phlebotomy chair. The patient is then moved to
another room to sit in a plastic lounge chair and given a pillow for an aim
rest The pillows have a zippered"plastic case which is washable. 'They
are tbea covered with a cloth,pillow case that iswashed routinely or if
soiled. Soiled cases are not reused. We also have disposable pillow
cases on hand. Thotegmph to be forwarded).
4) Please see photogaph provided for previous complaint#200453579.
All rV tar'bing is disposed of in a properly marked biohazard container
for regidated waste.
275 Mill Way,P.O.Box 73Z&unstebW,MA 02M
TeL MO)MUM Fax RM 39-ISZ
FROM PHONE NO. MAY. 08 1997 08:55AM P8
APR-07-97 07,45 FROM :U. S. D. O.L . OSHr, SOUTH ID: PACE 3/4
01/81/1995 06:56 5083621525 MICHHtl. J,u�uir
5) We have hstdled an eye wash station at the sink in our labmto►ty, (P'hatvgraph
to be&&warded). AN lab employees have been hutucted in its use.
6) There used to be two employees,Swxld a MacPhee and Arnie Moom who would
eat in the lab. They have not worked here since October,1996 and November
1996 respectively. Sand dumv,no employees eat in the lab.
As mentioActied above,several pha►t�ographs will be forwarded witliii the new flew
days,as soon as ffim is developed. If any other informaticm is needed,or if you have
any quesfions,please contact me, Kb6berleeAUen at any time.
The Comte of Posting was read and signed by an employees here and faxed back
to you on March 28,1997.
spy your,
)C=dwlee Allm PA-C
FROM : PHONE NO. : MAY. 08 1997 08:55AM P9
APR-07-97 07 : 48 FROM: U. S . D.O.L . OSHA . SOUTH I0 • PACE 4/4
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FROM PHONE NO. : MAY. 08 1997 06:56RM P10
Frank Reinhardt
P .O . Box 573
Hyannisport , MA 02647
Phone/Fax : 508-363-5210
May 7 , 1997
Complaint #200455244
Brenda J . Gordon
U. S. Department of Labor
Occupational Safety and Health Administration
639 Granite Street , 4th Floor
Braintree , MA 02184
Fax : 617-565-6923
Dear Ms . Gordon ,
I wrote to the American Medical Association about a
multitude of violations at the Center for Preventive Medicine
at 275 Mill Way , Barnstable, MA . These violations included
professional misconduct by Dr . Michael Janson and the Physician ' s
Assistant , Kim Allen . I have reported this misconduct to the
Board of Registration in Medicine and to the Division of Regi-
stration Office of Investigation . I also wrote to Mr . John
Phillips , Regional Administrator of OSHA after the letter
from the AMA stated to contact OSHA . OSHA then sent a letter
on 03-26-97 , complaint #200455244 to the Center for Preventive
Medicine, Dr . Michael Janson , P . O . Box 732 , Barnstable , MA
02630. Kim Allen wrote back to OSHA in a letter of March 31 ,
1997 denying all of the alleged hazards , except the eyewash
which they added.
In late April , the Board of Health in the town of Barn-
stable was contacted with complaints about unsanitary condi-
tions at the Center for Preventive Medicine. These complaints
came approximately one month after OSHA had sent the CPM their
letter of alleged complaints .
The Center. for Preventive Medicine , Dr . Michael Janson
and Kim Allen , P .A . have blatantly defied OSHA . The Barnstable
Board of Health inspected this site approximately one month
after OSHA ' s complaint letter of alleged hazards and found
unsanitary conditions and they have contacted a state agency
for further investigation.
Dr . Michael Janson and Kim Allen have told past employees
to disregard OSHA regulations . The medical. waste boxes are
too expensive to dispose of and the employees were told to
throw medical waste in the regular trash . Kim Allen directly
told one employee that all patients should be hooked up to
•their IV ' s in the laboratory wit-h the linoleum floor due to
OSHA regulations and about two minutes later when many patients
FROM : PHONE NO. MAY. 08 1997 08:57AM P11
Brenda J . Gordon
May 7 , 1997
Page Two
showed up all at once , Kim Allen stated to just hook the
patients up anywhere . This can easily be verified and shows
blatant disregard for safety and OSHA regulations .
I believe that after all of this information , that
Dr . Michael Janson, Kim Allen, P .A. and all employees should
be thoroughly tested by OSHA in all the aspects of the type
of medical practice they are running . I believe that Dr .
Janson and Kim Allen, P .A . don ' t know about all OSHA regu-
lations themselves and as a result , the employees don ' t know
them. I believe that the OSHA regulations that Dr. Janson
and Kim Allen do 'know about are being blatantly defied in
order to save money and increase profits . Another past em-
ployee was told by Kim Allen that compliance with OSHA
regulations is "too expensive . " I believe that all of this
information shows a dangerous lack of concern for employee ' s
and patient ' s safety and a lack of morals and ethics by the
Center for Preventive Medicine, Dr . Michael Janson and Kim
Allen .
Please feel free to contact me with any questions and
thank you for your anticipated cooperation in this matter .
Sincerely ,
Frank Reinhardt
cc : John T . Phillips
Regional Administrator
via fax
Center for Preventive Medicine
Michael Janson,M.D.
Q_ Kimberlee Allen, P.A.-C.
As
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275 Mill Way, P.O. Box 732, Barnstable,MA 02630
'rvi- (508)362-43,I3 lax. (508)362-1525
Health Complaints
27-Jan-98
Time: 3'00:00 PM Date: 1/23/98 Complaint Number: 1172
Referred To: GLEN HARRINGTON Taken By: L.S.
Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE
Article X Detail:
Business Name: DR. JANSSON
Number: 275 Street: MILLWAY
Village: BARNSTABLE Assessors Map-Parcel:
Complainant's Name: ANONYMOUS
Address:
Telephone Number:
Complaint Description: SHE FOUND AN OPEN BAG OF TRASH
BESIDE DUMPSTER WITH USED NEEDLES
IN IT.
Actions Taken/Results: gh inspected. I checked dumpsters. The
dumpster closer to the professional offices was
full. No syringes were observed in bags that
were in the dumpster. There was no debris or
bags of trash around or on the ground in the
vicinity of either dumpster. The dumpster at the
entrance of the parking area was empty. No
violations found. Woman who called reportedly
put bag back in dumpster. There are five
medical offices within the professional
buildings. Transformations-Center for Healing
& Hollistic Health, Barnstable Hollistic Center,
Homeopathic Clinic, Institute for Health &
Healing, Center for Prevention Medicine-Dr.
Janssen. I cannot cite one party or all parties
when there is no evidence left to identify a
violation. Each company had a small bio-
hazard container outside their doors.
Investigation Date: Investigation Time:
1
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ftMEro`♦ The Town of Barnstable
I DeaalT.HG I Department of Health, Safety and Environmental Services
Public Health Division
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367 Main Street,Hyannis,MA 02601
Office 508-790-6265 Thomas A.McKean
FAX 508-775-3344 Director of Public Health
June 11, 1997
Jamie MacDonald
Board of Registration of Medicine
10 West Street
Boston, MA 02111
Dear Jamie:
Attached are the records which you requested regarding 275 Mill Way, Barnstable, the
Center for Preventative Medicine.
Sincerely yours,
omas A. McKean
Director of Public Health
Town of Barnstable
TM/bcs
enclosure
medicine
Commonwealth of Massachusetts
Board of Registration in Medicine
z �
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I d 10 West Street
Boston, Massachusetts 02111 NISHAN J. K CHAIRMAN
AN, M.D.
� -
tie
BRUCE A. SINGAL
(617)727-3086
VICE-CHAIRMAN
Fax: (617) 451-9568 RAFIK ATTIA, M.D.
An Agency within the Office of Consumer Affairs and Business Re n 9 BOARD MEMBER
ALEXANDER F. FLEMING /w� A OLD S.RELMAN,M.D.
EXECUTIVE DIRECTOR `Y � �O BOARD MEMBER
PENELOPE WELLS L M. SAPERS
GENERAL COUNSEL �r�t g
A- }Ir,- 1� RD MEMBER
MARY SULLIVAN,M.D.
June 5, 1997 JUN i RD MEMBER
rpwN 1 0 1997PET MADRAS, M.D.
y�r egRNsrAa RD MEMBER
Thomas McKean Hofer
Director of Public Health A 4*
Health Department y
P.O. Box 534, 367 Main Street
Barnstable, MA 02601
Re: Center for Preventative Medicine,275 Mill Way,Barnstable,MA
Dear Mr. McKean:
I am a staff attorney in the Enforcement Division of the state licensing authority
for physicians and we are investigating Dr. Michael Janson, the physican owner of the
above facility. Earlier today I spoke with Christine Kutchinski from your office and I am
writing at her suggestion.
It is my understanding that Jerry Dunning from your department inspected the
above facility in late April 1997 in investigation of a report of unsanitary conditions by a
former patient named Frank Reinhardt that was referred to your office by OSHA. I am
requesting information about the results of that inspection such as any report Mr.
Dunning might have written.
If you have any questions about my interest in this matter,please call me at(617)
727-1788, ext. 307.
V5ry truly yours,
amie MacDonald.
e Complaint Counsel .
• n
Health Complaints
09-May-97
Time: 4:17:49 PM Date: 4/16/97 Complaint Number: 746
Referred To: JEROME DUNNING Taken By: L.S.
Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE
Article X Detail:
Business Name: CENTER FOR PREVENTIVE MEDICINE
Number: 275 Street: MILLWAY
Village: BARNSTABLE Assessors Map-Parcel:
Complainant's Name: ANONYMOUS
Address:
Telephone Number:
Complaint Description: IV THERAPY TUBING MATERIAL IS
DRAINED DOWN THE SINK- BLOOD,
URINE, AND CHEMICAL SOLUTIONS.
Actions Taken/Results: John MacLean (617 565-6924) Federal OSHA
called TM on 5/9/97 at approx. 9:00 a.m.. He
stated his is investigating. He was told by a
complainant that the Health Department went to
the site and found violations. TM explained that
is not true. Health Inspector Christina Kuchinski
telephoned the Division of Health Care(617
727-5860 X340) on April 22, 1997 and reported
the complaint. CK asked for Mary Chemini,
R.N. but she was not there. The secretary took
the information and said they would look into
the allegations and go out to the
property.
Brenda Gordan of OSHA called at 11:50 a.m.
on 5/9/97 and asked Health Division to go out to
the site and look for possible health violations
(e.g. discharging chemicals or blood products
into the septic system, any overflowing
contaminated needle boxes, needles laying
around, bloody gauzes, dry blood on tables,
1
Health Complaints
09-May-97
etc.). At 12:30, JD inspected Dr. Janson's
Office . No contaminated needles observed
overflowing from boxes, no blood products
observed, no bloody gauzes observed
Investigation Date: Investigation Time:
2
Health Complaints
16-Apr-97
Time: 4:17:49 PM Date: 4/16/97 Complaint Number: 746
Referred To: JEROME DUNNING Taken By: L.S.
Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE
Article X Detail:
Business Name: CENTER FOR PREVENTIVE MEDICINE
Number: 275 Street: MILLWAY
Village: BARNSTABLE Assessors Map_Parcel:
Complainant's Name: ANONYMOUS
Address:
Telephone Number:
Complaint Description: IV THERAPY TUBING MATERIAL IS
DRAINED DOWN THE SINK- BLOOD,
URINE, AND CHEMICAL SOLUTIONS.
Actions Taken/Results:
Investigation Date: Investigation Time:
1
^
150 Tremont St. • Boston,MA 02111 (Area code is 617.)
Commissioner's Office PHONE FLOOR
Commissioner David H.Mulligan 727-0201 1Oth
Administrative,assistant Kathy McLaughlin 727-0201 10th
Chief of Staff Mary Ann Hart 727-0201 1Oth
Public Information Kate McCormick 727-0201 1Oth
Associate Commissioners
Management Services James Hill 727-6194 loth
Policy&Planning Gerard Desilets 727-2692 loth
Policy&Planning Office
Legislative,Government Relations Kathleen Atkinson 727-2692 IOth
Local Health&Policy Liasion Hillel Liebert 727-2692 loth
Western Health Office (413)586-7525
Division Directors/Programs
AIDS Program John Auerbach 727-0368 1lth
Chronic Disease Prevention Lily Itsu 727-2662 7th
Communicable Disease Control Alfred DeMaria,MD 522-3700 State Lab
Community Health Programs Mary Leary 727-2013 7th
'Community Sanitation __gges arm Wensley 27 2660 State Lab
Dental Health Gregory 'onno y 727-3150 2nd
Elderly Health Promotion Alan Balsam 727-2662 7th
Environmental Health Assessment Suzanne Condon 170 7th
Health Care Systems Andrew Levine 727-2708
Laboratory Sciences Ralph Timperi 522-3700 State Lab
Lead Poisoning Prevention Brad Prenney 522-3700 State Lab
Non Smoking&Health Martha Wood 727-0752 2nd
Occupational Health Letitia Davis 727-2735 8th
Parent,Child&Adolescent Health Deborah Klein-Walker 727-3372 3rd
Radiation Control Rob isey State Lab
_R on gram(Statewide) William a 413) 6-7525
Statistics, Research,Evaluation Daniel Fmidman 727-6452 5th
Substance Abuse Services Dennis McCarty 727-8614 6th
Childhood Lead Poisoning Pmventlon Program 522-3700
Director Brad Prenney 177
Asst. Dir. Field Operations Paul Hunter 178
Asst. Dir.Case Management Mary Jean Brown,RN 180
Chief of Labs Phyllis Madigan 185
Program Coordinator Joseph DeCinti 179
Senior Planner Roy Petre 182
3
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Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS:-- NS�� - T `LWIT�
BUSINESS LOCATION: 2. S 1 GLW P"v JG M
MAILING ADDRESS: p 9 Mail To:
TELEPHONE NUMBER: 9-�Ll Board of Health
Town of Barnstable
CONTACT PERSON: P.O. Box 534 ,
EMERGENCY CONTACT TELEPHONE NUMBER: 1 /l S(08 �19 Hyannis, MA 02601
TYPEOFBUSINESS: 6kM1 LAT.-
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
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:
I TELEPHONE:
K .
f LIST OF TOXIC AND HAZARDOUS MATERIALS
t 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.
K
Quantity Quantity
i -
Antifreeze(for gasoline or coolant systems) Drain cleaners
I NEW USED Cesspool cleaners
f
Automatic transmission fluid. Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
i
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
4
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
{ Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
C 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 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
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: c e 004-," Board of Health
MAILING ADDRESS: 4846omsYf&_ 1*0 0430 Town of Barnstable
TELEPHONE NUMBER: Say .atoms. 77717 3C2- 2711 P.O. Box 534
CONTACT PERSON: /MAdfA,: Hyannis, MA 02601
Does your firm store any of the.toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totallin , at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? 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
characteristics and must be registered w0f 9fte-Y antitre`s' `a'i g reR a f tifd:,
f„ w,ae1ht. Please put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
Date: — _ lqq
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS:
BUSINESS LOCATION:oz
MAILINGADDRESS: -7Q Mail To:
� Board of Health
TELEPHONE NUMBER: Town of Barnstable
CONTACT PERSON: P.O. Box 534
EMERGENCY CONTACT ELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS:
Does your firm store a y of the toxic r hazardo materials listed below, either for sal 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 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 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 o hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS