Temporary or Permanent Closure of Food Establishment Inspection Application

All Food Establishments in Marblehead that are closing for a minimum of ten calendar days to permanent closure are to be inspected by the Board of Health.

Name of Establishment *

Address of Establishment *

Name of Applicant *

Applicant's Telephone Number *

Applicant's Cell Phone Number

Date of Closure *

Month

Day

Year

Re-opening Date *

Month

Day

Year

Reason for Closure *

Emergency Contact Name *

Emergency Contact Phone Number *

Landlord's Name *

Landlord's Telephone Number *

Additional Information Pertinent to the Closure for the Board of Health

Leave this field blank

Departments

Boards

Residents:

Visitors:

Local:

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Temporary or Permanent Closure of Food Establishment Inspection Application