This Section for Board of Health Use Only

Date Received ________ Date Inspected _______ Approved By _________ Permit # Issued _______

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Food Establishment Permit Application

(Application must be submitted at least 30 days before the planned opening date)

1. Establishment Name

2. Establishment Address

3. Establishment Mailing Address

4. Establishment Telephone #

Fax #

Email Address

5. Applicant Name & Title

6. Applicant Address

7. Applicant Telephone #

Emergency #

8. Owner Name and Title

9. Owner Address

10. Establishment Owned By:

An association A corporation An individual A partnership Other legal entity (must specify below)

.

11. If a corporation or partnership, give name, title and home address of officers or partner(s)

12. Person Directly Responsible for Daily Operations (Owner, Person in Charge, Supervisor, Manager, etc.)

Name & Title

Address

Telephone No.

Fax No.

Emergency Telephone No.

13. District or Regional Supervisor (if applicable)

Name & Title

Address

Telephone No.

Fax No.

14. Water Source

DEP Public Water Supply No.
(if applicable)

15. Sewage Disposal

16. Days and Hours of Operation

17. Number of Food Employees

18. Name of Person in Charge
who is Certified in Food
Protection Management

Required as of 10/1/2001 in accordance with 105 CMR 590.003(A). Please attach a copy of certificate.

19. Person Trained in
Anti-Choking Procedures
(if 25 seats or more)

Yes

No

20. Location

Permanent Structure

Mobile

21. Length of Permit

Annual Seasonal (must specify dates below) Temporary (must specify dates and times below)

.

22. Establishment Type
(check all that apply)

Retail * Food Service * Food Service - Takeout Food Service - Institution * Residential Kitchen for Retail Sale

Caterer Residential Kitchen for Bed and Breakfast Home Residential Kitchen for Bed and Breakfast Establishments Frozen Dessert Manufacturer Food Delivery

Other (Please specify)

* Retail - square footage

* Food Service - number of seats

* Food Service - Institution
Meals served per day

23. Food Operations

Definitions:
PHF - potentially hazardous food (time/temperature controls required)
Non-PHFs - non-potentially hazardous food (no time/temperature controls required)
RTE - ready-to-eat foods (examples: sandwiches, salads, muffins that need no further processing)

Check all that apply:

Sale of Commercially Pre-Packaged Non-PHFs Sale of Commercially Pre-Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 hours Customer Self-Service of Non-PHF and Non-Perishable Foods Only Preparation of Non-PHFs PHF Cooked to Order Preparation of PHFs for Hot and Cold Holding for Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Customer PHF and RTE Foods Prepared for Highly Susceptible Population Facility

Ice Manufactured and Packaged for Retail Sale Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out-of-Date or Reconditioned Food Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service Customer Self-Service Vacuum Packaging/Cook Chill Use of Process Requiring a Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw or Undercooked Food of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service

Other (Please Describe)

I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code.

24. Signature of Applicant _____________________________________________________________

25. Social Security Number
or Federal ID

Signature of Individual or Corporate Name __________________________________________________

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(To be completed by Board of Health)

Permit Fees: (Payment is due with application)

FOOD SERVICE - $175 RETAIL FOOD - $150 FOOD SERVICE and Retail Food - $180

SEASONAL - $50 MILK & CREAM - $2

Total Permit Fee __________________