Plan Review, Food Establishment, Frozen Dessert Applications with
Guidelines and Workers Compensation FormNewton, MA 02459 Telephone
617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
Complete the Following Application(s). Please Print Legibly.
Incomplete applications and missing documents may cause a delay in
the decision-making process.
Date: Type of Food Operation
Restaurant Retail Market Frozen Dessert Manufacturer - Retail &
Wholesale Complete Attachment A: Frozen Dessert License
Application
Institution Daycare Other (Specify):
New Remodel Conversion
Name of Establishment: Establishment Address: Newton, MA Zip: 024
Establishment Phone: Number: 617- Name of Owner: Owner’s Mailing
Address: Owner’s Phone Number: Email: Applicant’s Name: Email:
Title: Owner Manager Contractor Architect Other: Applicant’s
Mailing Address: Applicant’s Phone Number:
HOURS OF OPERATION
Sun Mon Tue Wed Thu Fri Sat Will the establishment apply for
seating? Yes No
• Please Note: According to MA General Law Chapter 140 Section 2,
Food Establishments that offers seating to the Public for
consumption on the premises requires a Common Victualler (CV)
License. Additionally, According to MA General Law, Food Service
Establishments with 25 or more seats are required to have an
employee trained in Anti-Choking procedures at all times the
establishment is open to the public.
2
If known, number of Seats authorized by CV: NA (No seats) Will the
establishment apply for an Alcohol License?
Yes No
FOOD ESTABLISHMENT
Area of Facility (ft²): Number of Floors: Maximum # of Meals to be
served (approximate): Breakfast: Lunch: Dinner:
TYPE OF SERVICE(S)
Sit Down Meals Take Out Only Caterer Single-Use Utensils Multi-Use
Utensils Will the establishment have entertainment (music,
television etc.)? Yes No Will the establishment have Sunday
entertainment? Yes No Will there be outdoor dining? Yes No
FOOD SUPPLY Food Sources (Company Name(s)):
• Foods to be sold at a retail operations shall be purchased from
licensed wholesale operations
How often will refrigerated foods be delivered? How often will
frozen foods be delivered? How often will dry goods be
delivered?
Provide the amount of space (cubic feet) allocated for:
Refrigerator Storage: Freezer Storage: Dry Storage: Identify the
location and containers that will be used to store bulk food
products (rice, sugar etc.): List all foods that will be cooked and
cooled: List all foods that will be cooked, cooled and reheated:
List all foods that will be hot held prior to service:
3
Ready to Eat Foods (RTE) (e.g. salads, cold sandwiches, and raw
molluscan shellfish):
Produce:
Poultry:
Meat:
Hot holding for service of TCS (Time / Temperature Control for
Safety Food) Foods Maintained at 135°F and above
Type of unit(s): Number of unit(s):
Location:
Cold holding for service of TCS Foods - Maintained at 41°F and
below
Type of unit(s): Number of unit(s):
Location:
Will any of the following Special Processing Methods be used? Yes
No • Reduced Oxygen Packaging (ROP), Use of Additives to Render a
Food Non-TCS (Acidification), Curing and
Smoking for Preservation, Cook-Chill, Sous Vide, Live Molluscan
Shellfish Tank, Sprouted Seeds, Fermenting
Some Special Processes require a HACCP(Hazard Analysis Critical
Control Point) Plan and / or a Variance Please Note: There is an
additional $50.00 Fee for the Review of Special Processes /
Variance Requests
Will a HACCP Plan be submitted? Yes No • If yes, in addition to
this application, complete the “Hazard Analysis Critical Point Plan
Review Application”.
Will a request for a Variance be requested? Yes No
• If yes, complete the “Request for Variance Form” including the
“Granted Variance” Section of the form Will the establishment
partially cook Animal Foods? Yes No
• If yes, a plan must be submitted for review and approval Will the
establishment use Time as a Public Health Control? Yes No • If yes,
complete “Time as a Public Health Control (TPHC) Request”
form
Explain the Handling / Preparation Procedures for the following
categories of food. Describe the processes from receiving to
service including:
1. How the food will arrive (frozen, fresh, packaged, etc.) 2.
Where the food will be stored 3. Where the food will be washed,
cut, marinated, breaded, cooked etc. (prep table, sink, counter
etc.) 4. When food will be handled / prepared (time of day and
frequency / day)
4
Seafood:
Will the basement (if applicable) be used? Yes No What will the
basement (if applicable) be used for: Food Preparation Storage Only
Note: If the basement will be used for Food Preparation, the
submitted plans shall include the layout and equipment
specifications.
Explain how the basement will be used for food preparation: PEST
CONTROL Will all outside doors be self-closing and rodent proof?
Yes No Will screens be provided on all entrances left open to the
outside? Yes No Will all openable windows have mesh screening
(minimum #16 mesh)? Yes No Will air curtains be used? Yes No
• If yes, where will they be located? WATER SUPPLY What is the
capacity and location of the water heater?
Will an ice machine be installed? Yes No • If yes, where?
WARE & DISHWASHING
Will the largest pot & pan fit into each compartment of the
3-compartment sink? Yes No If No, describe the cleaning method that
will be used: Describe the location & type of device used for
air drying clean equipment: Will a dish / glass machine be used?
Yes No
• If yes, what will be the final rinse sanitizing cycle? Hot Water
Chemical Will the dish / glass machine final rinse be under
pressure?
Yes No • If yes, will the machine have a pressure gauge? Yes
No
Will the machine be equipped to automatically dispense detergents
and sanitizers? Yes No What type of device will be installed on the
ware washing machine to verify that detergents and sanitizers are
delivered or not delivered to the respective washing and sanitizing
cycles? Visual Audible Please note: A ware washing machine shall be
equipped to automatically dispense detergents and sanitizers and
incorporate a visual means to verify that detergents and sanitizers
are delivered or a visual or audible alarm to signal if the
detergents and sanitizers are not delivered to the respective
washing and sanitizing cycles. What type of sanitizer and the brand
name will be used on food contact surfaces?
Chlorine: Quaternary:
Yes No
• If no, where will employees store personal items? Identify the
storage location for poisonous or toxic materials (chemical
storage):
Identify how grease will be disposed:
How often will the grease trap(s) be cleaned?
Identify the location of grease storage containers:
REFUSE Will refuse / garbage be stored inside? Yes No
• If yes, describe where: Identify how and where garbage cans and
floor mats will be cleaned:
Will a dumpster be used? Yes No
• If yes, how many? Size: Frequency of pick-up: Name of company
used for dumpster pick-up: Name of company used for grease
pick-up:
Note: All Waste Disposal Companies (Offals) must be licensed with
the City of Newton Health and Human Services Department Describe
the surface and location where the dumpster / garbage will be
stored outside:
Is there a Written Employee Health Policy for ALL Employees’? Yes
No
• If yes, provide a copy of the Written Employee Health Policy • If
no, the FDA “Employee Health and Personal Hygiene Handbook” can be
used to develop a Written Policy
The Handbook can be obtained online
http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or
Projected Start Date: Projected Completion
Date: Projected Establishment Opening Date:
Please Note: After six (6) months if the work has not started or an
extension has not been granted by the Newton
Health and Human Services Department, your plan review application
will be considered null and void. Fees will not be refunded.
Fiberglass Reinforced Panels (FRP), Ceramic Tile etc.).
AREA
FLOOR
Completed Food Establishment Plan Review Application Form
All Applicable Fees. Cash is not accepted. Please make checks /
money orders made payable to the “City of Newton”. All Fees are
non-refundable.
A copy of the Written Employee Health Policy (if new establishment
and / or new owner)
Proposed Menu or complete list of food and beverages to be offered
(Including seasonal, off site and banquet / catering menus)
Plan(s) or Sketch of Food Establishment drawn to scale showing
location of equipment, plumbing, electrical and mechanical
services
Equipment schedule including location, plumbing, drain and
electrical connections
Manufacturer Equipment Specification Sheets for each piece of
equipment to be used in the Food Establishment
Previously “used” or refurbished equipment must be evaluated by a
Certified Refrigeration Company / HVAC (Heating Ventilation and Air
Conditioning) / Professional. This evaluation must be
submitted
Site plan showing location of food establishment location of
building on site including alleys, streets and location of any
outside equipment or facilities (dumpsters, well, septic system if
applicable)
Completed Application for Permit to Operate a Food Establishment
(if new establishment and / or new owner)
Workers’ Compensation Insurance Affidavit
Certified Food Manager’s Certificate Allergy Awareness Certificate
Choke Save Training Certificate
Completed Frozen Dessert Application (if applicable)
HACCP (Hazard Analysis Critical Control Plan) Plan Review
Application (if applicable) containing all required information
(for Special Processes requiring a HACCP Plan)
Request for Variance (if applicable) for Special Processes and Time
as a Public Health Control
Please note that any missing information may cause a delay in the
decision making process
STATEMENT: I, hereby certify that the above information is correct
and I fully understand that any deviation from the above without
prior permission from the Newton Health and Human Services
Department may nullify final approval. Signature: Title:
Print Name: Date:
Approval of these plans and specifications by this Regulatory
Authority does not indicate compliance with any other code, law or
regulation that may be required – Federal, State or Local. It
further does not constitute endorsement or acceptance of the
completed establishment (structure or equipment). A preopening
inspection of the establishment with equipment in place and
operational will be necessary to determine if it complies with the
Local and State Laws governing Food Service Establishments.
FOR OFFICIAL USE ONLY Date Submitted: Fee Received: $ Check #: Risk
Category: 1 A / 1 B
$50.00 2
$50.00 3
$100.00 4A
$150.00 4B
The Food Codes can be found at the following websites:
http://www.Newtonma.gov/health
State Sanitary Code Chapter X – Minimum Sanitation Standards for
Food Establishments 105 CMR 590.000:
http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code:
http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
FDA 2013 Food Code Supplement:
http://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm453530.htm
Frozen Desserts and Frozen Dessert Mixes 105 CMR 561.000:
www.mass.gov/eohhs/docs/dph/regs/105cmr561.rt
The Health and Human Services Department is open 8:30 A.M. - 5:00
P.M. M-F and until 8:00 P.M. on Tuesdays If there are questions
please call the Health and Human Services Department at
617-796-1420
RISK CATEGORIZATION OF FOOD ESTABLISHMENTS
RISK CATEGORY DESCRIPTION FREQUENCY
1 (A & B)
Examples include most convenience store operations, hot dog carts,
and coffee shops. Establishments that serve or sell only
pre-packaged, non time/temperature control for safety (TCS) foods.
Establishments that prepare only non-TCS foods. Establishments that
heat only commercially processed, TCS foods for hot holding. No
cooling of TCS foods. Establishments that would otherwise be
grouped in Category 2 but have shown through historical
documentation to have achieved active managerial control of
foodborne illness risk factors.
1
2
Examples may include retail food store operations, schools not
serving a highly susceptible population, and quick service
operations. Limited menu. Most products are prepared/cooked and
served immediately. May involve hot and cold holding of TCS foods
after preparation or cooking. Complex preparation of TCS foods
requiring cooking, cooling, and reheating for hot holding is
limited to only a few TCS foods. Establishments that would
otherwise be grouped in Category 3 but have shown through
historical documentation to have achieved active managerial control
of foodborne illness risk factors. Newly permitted establishments
that would otherwise be grouped in Category 1 until history of
active managerial control of foodborne illness risk factors is
achieved and documented.
2
3
An example is a full service restaurant. Extensive menu and
handling of raw ingredients. Complex preparation including cooking,
cooling, and reheating for hot holding involves many TCS foods.
Variety of processes require hot and cold holding of TCS food.
Establishments that would otherwise be grouped in Category 4 but
have shown through historical documentation to have achieved active
managerial control of foodborne illness risk factors. Newly
permitted establishments that would otherwise be grouped in
Category 2 until history of active managerial control of foodborne
illness risk factors is achieved and documented.
3
PLAN REVIEW APPLICATION GUIDELINES FOOD ESTABLISHMENT
The following items are required to be submitted for a complete
plan review. Any missing information could cause a delay in the
process. After six months if the work has not started or an
extension has not been granted by the Newton Health and Human
Services Department, your plan review application will be
considered null and void. Fees will not be refunded.
1) Other than Establishments which sell only commercially packaged
foods all other Food Establishments are
required to have a Person in Charge (PIC) who is a Certified Food
Protection Manager. The PIC shall be a full-time employee at least
18 years of age. If the Certified Food Protection Manager is not
present at the establishment, there must be a designated PIC who
can demonstrate the same level of knowledge as required by the
Certified Food Manager. Certified Food Manager class instructors
can be found at the MA Food Protection Program website:
http://www.mass.gov/eohhs/docs/dph/environmental/foodsafety/food-safety-exam-trainers.pdf
In addition, the Certified Food Protection Manager must obtain a
certificate showing that they viewed the Allergen Awareness
Training video. The PIC will be responsible for training the
employees on allergy awareness. The Certified Food Protection
Manager and Allergy certificates shall be prominently posted in the
establishment next to the food establishment permit and the Common
Victualler license (if applicable). The video can be viewed on the
MA Food Protection Program website:
http://www.mass.gov/dph/fpp
Each food establishment having a seating capacity of 25 persons or
more have on its premises, while food is being served, an employee
trained in manual procedures to remove food lodged in a person’s
throat. Proof of training for choke save must be available on site.
All of these certificates must be obtained PRIOR to opening.
Classes are offered in Newton and Framingham on a monthly basis.
The class schedule can be obtain on the City of Newton’s website:
http://www.newtonma.gov/gov/health/enviro/forms/food.asp A written
Employee Health Policy must be submitted. The policy should consist
of excluding and restricting employees on the basis of their health
and activities as they relate to diseases that are transmissible
through food. Written policy includes a statement regarding
employee responsibility to notify management of symptoms and
illness identified in the Food Code. The “FDA Employee Health and
Personal Hygiene Handbook” contains forms and is a great resource
that can be used. The handbook can be found at:
http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or on the
City of Newton’s website:
http://www.newtonma.gov/gov/health/enviro/forms/food.asp
2) Provide plans that are a minimum of 11 x 14 inches in size
including the layout of the floor plan accurately drawn
to a minimum scale of ¼ inch = 1 foot. Plans shall include:
• Proposed menu: List any food that will be prepared overnight,
special processes, projected daily meal volume for food service
operations, seating capacity and food sources.
• Food equipment schedule to include make and model numbers and
listing of equipment that is certified or
classified for sanitation by an ANSI accredited certification
program.
• All new or replaced equipment must be capable of cooling and
holding internal food temperatures at 41ºF and below.
• All existing refrigeration equipment must be evaluated by a HVAC
(Heating, Ventilation, Air
Conditioning) Specialist certifying that the equipment is capable
of cooling and holding internal food temperatures at 41ºF and
below. Any existing dish / glass machine must also be evaluated by
an industry certified technician. Reports should be submitted as
part of the Plan Review.
3) Show the location and when requested, elevated drawings of all
food equipment.
• Each piece of equipment must be clearly labeled on the plan with
its common name.
• Submit drawings of self-service hot and cold holding units with
sneeze (breath) guards.
• Designate clearly on the plan equipment for rapid cooling,
including ice baths, refrigeration and hot holding.
• Label all sinks and the designated use i.e. hand washing,
utensils cleaning, food prep etc. 4) Provide on the Floor Plan:
Room size, aisle space, space between and behind equipment and the
placement of
the equipment. 5) Show all auxiliary areas such as storage rooms,
garbage rooms, toilets, basements used for storage or food
preparation. Include and provide specifications for: Entrances,
exits, loading / unloading areas and docks.
• Complete finish schedules for each room including floors, walls,
ceilings and coved juncture bases.
• Plumbing schedule including location of floor drains, floor
sinks, water supply lines, overhead wastewater lines, hot water
generating equipment with capacity and recovery rate, backflow
prevention and wastewater line connections.
• Lighting schedule with a shield, coating, or otherwise
shatter-resistant :
At least 540 lux (50 foot candle) at food prep areas where
employees work with sharp or mechanical equipment.
220 lux (20 foot candle) at food service / preparation areas. 110
lux (10 foot candle) in storage areas.
• Source of water supply and method of sewage disposal.
6) A color-coded flow chart demonstrating flow patterns for:
• Food : Receiving, Storage, Preparation, Service
• Food and Dishes: Portioning, Transport, Service
• Dishes: Clean, Soiled, Cleaning, Storage
• Utensils: Storage, Use, Cleaning
• Trash and Garbage: Service Area, Holding, Storage 7) Ventilation
schedule for each room. 8) Placement for mop sink / curbed cleaning
facility with designated area for hanging wet mops. 9) Cabinets /
Areas for storing toxic chemicals. 10) Dressing rooms, locker
areas, employee rest area, coat rack. 11) Site plan for new
construction.
Updated 4/9/18
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION FOR LICENSE TO MANUFACTURE FROZEN DESSERTS AND /
OR
ICE CREAM MIX In accordance with the provisions of Massachusetts
General Law Chapter 94, Section 65H and 105 CMR 561.000 Frozen
Desserts and Frozen Dessert Mixes, the undersigned hereby applies
for a license for the wholesale / retail manufacture of frozen
desserts and or ice cream mix.
Please Print Legibly
Establishment Phone Number: New Establishment Existing
Establishment Same as above
If not the same as above, list the location of each establishment
(plant) where product(s) will be manufacture:
Applicant’s Name:
Applicant’s Address:
Owner’s Name:
Type of Business Retail Manufacturer Wholesale Manufacturer
If Wholesale Manufacturer, brand and trade name(s) of
products:
Type of Product
Frozen Yogurt (not soft serve)
Frozen Yogurt (not soft-serve)
Sorbet (only if dairy-based) Other:
If Frozen Yogurt is manufactured, will it contain “friendly”
cultured bacteria (live cultures)? Yes No
12
Described the following Source(s) of Ingredients:
No milk or cream from a source outside of the United States,
subject to the Federal Import Milk Act, 21 U.S.C §141 et seq.,
shall be used unless the importer has documentation to show that
the exporter is in compliance with 21 CFR Part 1210.
Will a Soft-Serve Machine(s) be used? Yes – Type of Machine:
No
How many machines?
Submit the specification sheets for the machine(s)
If No, describe how the product will be prepared and the storage of
the final product:
Will commercially pasteurized product(s) be used? Yes No
If No, describe what will be used and how:
Will the above final product be pasteurized? Yes No
If Yes, describe the pasteurization process:
How will the refrigerated and frozen product be delivered and
transported?
If transported, how will the product temperature be
monitored?
How often will the surfaces and equipment be cleaned and
sanitized?
What are the procedures for cleaning the equipment and surfaces and
what product will be used?
How will the equipment and surfaces be sanitized?
Name and Type of Sanitizer:
13
All manufactured frozen desserts produced shall have the following
tests performed by a certified laboratory on its finished product
monthly.
Bacterial and other Standards shall not exceed the following
standards Item Standard Plate Count (SPC) Coliform
Finished Products Produced by means other than a Soft-Serve
Machine
50,000/g
20/g
50,000/g
50/g
** If Frozen Yogurt contains “live cultures”, SPC laboratory
testing is not required **
Copies of all test results for required tests shall be submitted
directly to the Newton Health and Human Services by the certified
laboratory within three (3) business days of the completion of the
tests.
SUBMIT THE FOLLOWING
Completed Application for License to Manufacture Frozen Desserts
and / or Ice Cream Mix
Completed Food Establishment Plan Review and Food Establishment
Application (for new food establishments only) including all of the
required documents. Page 6 on the Plan Review Application contains
the required documents. License fee of $5.00
Note: This can be included in the total fee for the Plan Review and
Food Establishment Permit Equipment Specification sheets used in
the process (i.e. Soft-Serve Machine(s) etc.) For existing food
establishments, provide a sketch of the processing area and / or
the placement of the Soft-Serve Machine(s)
ALL APPLICATIONS MUST BE FILLED OUT COMPLETELY WITH A FEE PAYABLE
TO THE “CITY OF NEWTON”
CASH AND CREDIT CARDS ARE NOT ACCEPTED AT THIS TIME ALL FEES ARE
NON-REFUNDABLE
Please note that any missing information may cause a delay in the
decision making process.
STATEMENT: I,
hereby certify that the above information is
correct and I fully understand that any deviation from the above
without prior permission from the Newton Health and Human Services
Department may nullify final approval. Additionally, I certify I
will manufacture such products only from pure and wholesome
ingredients and only under sanitary conditions.
Signature:
Title:
• What types of establishments are considered frozen dessert
manufacturers?
1.Wholesale manufacturing plants that pasteurize raw milk and
cream; 2.Wholesale manufacturers who purchase a pasteurized mix and
manufacture ice cream; 3.Retail manufacturers* who purchase a
pasteurized mix and manufacture ice cream, soft-serve ice cream or
frozen yogurt in a “frozen dessert freezing / dispensing machine.”
*It is important that the term manufacturer be understood as it
pertains to frozen desserts. The term manufacturer or frozen
dessert manufacturer as it appears in the regulations includes any
retail establishment operating a frozen dessert freezing/dispensing
machine. A “frozen dessert freezing/dispensing machine” is any
machine that freezes, mixes and dispenses frozen desserts. This
includes soft serve machines frequently operated at the retail
level. This means that all frozen dessert manufacturers, whether
wholesale or retail, require licensing by the local board of health
having jurisdiction.
• What types of establishments are NOT considered frozen dessert
manufacturers? 1.Stores and restaurants that purchase ice cream in
bulk and scoop it, but do not make ice cream in a frozen dessert
freezing/dispensing machine; 2.Retail stores that purchase ice
cream or other frozen desserts in pre-packaged retail containers
for re-sale to the public; 3.Vending machines that dispense
packaged ice cream, novelties, etc.; and 4.“Dispensing only
machines.” Dispensing only machines are machines that dispense a
prepackaged ready-to-use frozen dessert. These machines do not mix
or freeze a mixture. They merely dispense it. Therefore the machine
is not considered a manufacturing machine.
Testing and Testing Exemptions
105 CMR 561.007 states that all manufacturers must have their
frozen dessert products tested monthly by an approved laboratory.
Section 561.007(F) (2) (a) refers to seven categories of frozen
dessert products. The intent is to require bacteriological testing
for dairy-based frozen desserts only. Dairy-based frozen desserts
such as ice cream, sherbet and frozen yogurt are frozen dessert
products that contain dairy ingredients. Non-dairy frozen desserts
no longer require bacteriological testing. Non-dairy frozen
desserts, such as sorbet, water ices, Italian ice, slush and some
frozen coffee beverages are frozen desserts that do not contain any
dairy ingredients. These products do not pose the same potential
for supporting pathogenic organisms as do frozen desserts that do
contain dairy ingredients. Therefore, testing of non-dairy frozen
desserts is no longer required. According to 105 CMR 561.007 all
frozen dessert manufacturers (this includes soft serve dispensing
machines and ice cream barrel freezers) shall have bacteriological
tests performed on at least one dairy-based frozen dessert product
per month by a certified laboratory. The laboratory must submit
copies of the results to the board of health upon completion of the
analysis. If the SPC is above the 50.000 limit, the
Person-in-Charge (PIC) shall: 1. Review the cleaning and
sanitization procedures for the machine. Check the machine’s
specification sheets for additional instructions and cleaning
protocols for the machine. 2. Evaluate the handling of the products
/ ingredients. 3. If SPC is above the limit for two (2) consecutive
samplings, additional sampling will be required. If the Coliform
Count is above the 20/g (produced other than from a soft-serve
machine) or 50/g (products from a soft-serve machine), the PIC
shall: 1.Review the cleaning and sanitization procedures for the
machine. Check the machine’s specification sheets for additional
instructions and cleaning protocols for the machine. 2. Evaluate
the handling of the products / ingredients. 3. If one (1) sample is
above the required standard, resampling will be required. The
presence of coliform is an indicator of inadequate operational
sanitation and controls somewhere in the process. Bacteria counts
slightly above the standards should be a wake -up call. It should
alert the machine operator that something might not be right with
cleaning, temperature, storage or handling. If a high coliform
count is found (coliform count is an indicator that pathogens might
be present), further testing is necessary to confirm actual
pathogens.
15
Helpful Recommendations
• Check all pieces of the machines components for pitting, cuts,
clean ability etc. Often worn parts can lead to bacteria problems
even when cleaning and sanitizing are completed properly.
• Be sure to follow the disassembling, cleaning, sanitizing and
assembly of the frozen dessert machines are performed as indicated
by manufacturers’ recommendation and at the required frequency.
Verify the machine has been maintained properly.
• Wear gloves when assembling the machine. Be sure to wash hands
properly prior to glove use. .
Codes can be found at the following websites:
City of Newton http://www.newtonma.gov/health
MA State Sanitary Code Chapter X -
Minimum Sanitation Standards for Food Establishments 105 CMR
590.000
https://www.mass.gov/files/documents/2018/10/09/105cmr590.pdf
FDA 2013 Food Code
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION PERMIT TO OPERATE A FOOD ESTABLISHMENT
Complete the application below legibly. Enclose a fee payable to
the “City of Newton” Cash is not accepted. Fees are non-refundable.
Incomplete application may delay the permitting process.
Date: Type of Food Establishment: Mobile Stationary Temporary
Permanent
Check One Check One
Will containers of Milk be sold? Yes No
If Yes, include a $10 Milk License Fee
Will Frozen Dessert(s) be Manufactured? Yes No
If Yes, complete a Frozen Dessert License Application
Will Catering be offered? Yes No
Catering is defined as Delivering AND Serving
Will there be seating? Yes No Number of Seats approved by Common
Victualler (CV) License: Applicant’s Name: Title:
• To Quality for a Food Establishment Permit, an Applicant shall be
an Owner or an Officer of the Legal Ownership
Mailing Address:
The Food Establishment is Legally Owned by (check one):
Association Corporation Individual Partnership Other :
Name of Legal Food Establishment Owner (as per the CV License
application if applicable):
Owner’s Home Address:
Name of Contact Person (if Association, Corporation or
Partnership):
Phone #: Email: • If Corporation, Association or Partnership,
please attach a list of the Officer’s Names, Address and Phone
Numbers
A. Name of Person Directly Responsible for the Food
Establishment:
Title:
Address:
Phone #: Email:
B. Name of Person who functions as the Immediate Supervisor of the
Person listed in A above:
Title: Zone Supervisor District Supervisor Regional Supervisor
Other : Address:
Phone #: Email: Name of Emergency Contact Person: 24 Hour Phone
#:
17
Statement: I, affirm to comply with the MA Department of Public
Health State Sanitary Code Chapter X – Minimum Sanitation Standards
for Food Establishments (105 CMR590.000), the FDA Food Code and
allow the regulatory authority access to the establishment as
specified under § 8-402.11 and to the records specified under §
3-203.12, 5-205.13, 8-201.14(D)(6) and other information required
by the regulatory authority. I understand that any deviation from
the submitted and approved plan without prior approval from the
Newton Health and Human Services Department may cause a delay in
the permit process. Pursuit to M.G.L Chapter 62C, Section 49A, I
hereby certify under the pains and penalties of perjury that, to my
best knowledge and belief, the information provided above is true
and correct and that I have filed all state tax returns and paid
all state taxes required under law.
Federal Identification Number:
Food Establishment Fee: (based on Risk Category assigned) $
Milk License (only if cartons of milk are sold): $
Frozen Dessert Manufacturing
Total Amount Enclosed: $
To obtain a permit to operate a Food Establishment please submit
the following:
Completed “Application for a Permit to Operate a Food
Establishment”. Please print legibly. Any missing information may
cause a delay in the permit process. Do not leave any blank
spaces.
According to MA General Law Chapter 140 Section 2, Food
Establishments that offer seating to the public for consumption on
the premises requires a Common Victualler (CV) License.
Permit Fee (determined by the Newton Health and Human Services
Department) made payable to the “City of Newton”. Cash is not
accepted. All fees are non-refundable.
Completed “Workers’ Compensation Insurance Affidavit”. Attached a
copy of the workers’ compensation policy declaration page (showing
the policy number and expiration date).
A copy of your Written Employee Health Policy (if New Owner or New
Food Establishment).
A copy of the Person-in-Charge (PIC) Certified Food Protection
Manger AND Allergy Awareness Certificates (if New Owner or Food
Establishment).
Copy of Choke Save card or certificate. Food Service Establishments
with 25 or more seats are required to have an employee trained in
Anti-Choking Procedures at all times the establishment is open to
the public (if New Owner or Food Establishment).
Note: The Newton Health and Human Services (HHS) Department must be
notified PRIOR to the following:
• Remodeling / Changing Equipment.
• Adding Special Processes such as but not limited to: Smoking of
Foods / Acidification as means of Food Preservation, Reduced Oxygen
Packaging (ROP), Partial Cooking of Raw Animal Foods, and Using
Time as a Public Health Control. Detail plans and specific
information must be submitted for review.
Written approval must be granted by the Department prior to
implementing such processes.
Food Establishment Fee Schedule The Risk Category for the Food
Establishment is assigned by the HHS Department
Milk License (selling containers of Milk): $10.00 Special Process
Plan Review: $50.00 Risk Category 1A (only Commercially Packaged
Foods, Convenience Stores): $50.00 Risk Category 1B (Coffee Shops,
Residential Kitchens, Limited Operations) $150.00 Risk Category 2:
$250.00 Risk Category 3: $300.00 Risk Category 4A (Highly
Susceptible Populations (HSP) such as Preschools, Hospitals,
Nursing Homes; Food Establishments with Special Processes):
$300.00
Risk Category 4B (Supermarkets): $400.00 The Health and Human
Services Department is open M – F from 8:30 A.M. - 5:00 P.M. and
until 8:00 P.M. on Tuesdays.
If there are questions, please call the Health and Human Services
Department at 617-796-1420
18
The Food Codes can be found at the following websites:
105 CMR 590.000
http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code
http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
Office of Investigations Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Name:_________________________________________ __________
City/State/Zip:_____________________________ Phone
#:________________________________
*Any applicant that checks box #1 must also fill out the section
below showing their workers’ compensation policy information. **If
the corporate officers have exempted themselves, but the
corporation has other employees, a workers’ compensation policy is
required and such an organization should check box #1.
I am an employer that is providing workers’ compensation insurance
for my employees. Below is the policy information.
Insurance Company
Name:______________________________________________________________________________
Insurer’s
Address:_____________________________________________________________________________________
City/State/Zip:
________________________________________________________________________________________
Policy # or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers’ compensation policy declaration page
(showing the policy number and expiration date).
Failure to secure coverage as required under § 25A of MGL c. 152
can lead to the imposition of criminal penalties of a fine up to
$1,500.00 and/or one-year imprisonment, as well as civil penalties
in the form of a STOP WORK ORDER and a fine of up to $250.00 a day
against the violator. Be advised that a copy of this statement may
be forwarded to the Office of Investigations of the DIA for
insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that
the information provided above is true and correct. Signature:
Date: Phone #:
Official use only. Do not write in this area, to be completed by
city or town official.
City or Town: ___________________________________ Permit/License
#_________________________________
Issuing Authority (check one): Building Department 3. City/Town
Clerk 4.1. Licensing Board Board of Health 2.
5. Selectmen’s Office 6. Other _______________________________
Contact Person:_________________________________________ Phone
#:_________________________________
1. I am a employer with _________ employees (full and/ or
part-time).* 2. I am a sole proprietor or partnership and have no
employees working for me in any capacity. [No workers’ comp.
insurance required] 3. We are a corporation and its officers have
exercised their right of exemption per c. 152, §1(4), and we have
no employees. [No workers’ comp. insurance required]** 4. We are a
non-profit organization, staffed by volunteers, with no employees.
[No workers’ comp. insurance req.]
Are you an employer? Check the appropriate box: Business Type
(required): 5. Retail
6. Restaurant/Bar/Eating Establishment
8. Non-profit
9. Entertainment
10. Manufacturing
City or Town Officials
Please be sure that the affidavit is complete and printed legibly.
The Department has provided a space at the bottom of the affidavit
for you to fill out in the event the Office of Investigations has
to contact you regarding the applicant. Please be sure to fill in
the permit/license number which will be used as a reference number.
In addition, an applicant that must submit multiple permit/license
applications in any given year, need only submit one affidavit
indicating current policy information (if necessary). A copy of the
affidavit that has been officially stamped or marked by the city or
town may be provided to the applicant as proof that a valid
affidavit is on file for future permits or licenses. A new
affidavit must be filled out each year. Where a home owner or
citizen is obtaining a license or permit not related to any
business or commercial venture (i.e. a dog license or permit to
burn leaves etc.) said person is NOT required to complete this
affidavit. The Office of Investigations would like to thank you in
advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department’s address, telephone and fax number: The
Commonwealth of Massachusetts
Department of Industrial Accidents Office of Investigations
Lafayette City Center 2 Avenue de Lafayette,
Boston, MA 02111-1750
Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749
www.mass.gov/dia Form Revised 7/2019
Massachusetts General Laws chapter 152 requires all employers to
provide workers’ compensation for their employees. Pursuant to this
statute, an employee is defined as “...every person in the service
of another under any contract of hire, express or implied, oral or
written.” An employer is defined as “an individual, partnership,
association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the
legal representatives of a deceased employer, or the receiver or
trustee of an individual, partnership, association or other legal
entity, employing employees. However, the owner of a dwelling house
having not more than three apartments and who resides therein, or
the occupant of the dwelling house of another who employs persons
to do maintenance, construction or repair work on such dwelling
house or on the grounds or building appurtenant thereto shall not
because of such employment be deemed to be an employer.” MGL
chapter 152, §25C(6) also states that “every state or local
licensing agency shall withhold the issuance or renewal of a
license or permit to operate a business or to construct buildings
in the commonwealth for any applicant who has not produced
acceptable evidence of compliance with the insurance coverage
required.” Additionally, MGL chapter 152, §25C(7) states “Neither
the commonwealth nor any of its political subdivisions shall enter
into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements
of this chapter have been presented to the contracting
authority.”
Applicants Please fill out the workers’ compensation affidavit
completely, by checking the boxes that apply to your situation and,
if necessary, supply your insurance company’s name, address and
phone number along with a certificate of insurance. Limited
Liability Companies (LLC) or Limited Liability Partnerships (LLP)
with no employees other than the members or partners, are not
required to carry workers’ compensation insurance. If an LLC or LLP
does have employees, a policy is required. Be advised that this
affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to
sign and date the affidavit. The affidavit should be returned to
the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should
you have any questions regarding the law or if you are required to
obtain a workers’ compensation policy, please call the Department
at the number listed below. Self-insured companies should enter
their self-insurance license number on the appropriate line.
Applicants
Slide Number 1
Slide Number 2
Slide Number 1
Slide Number 2
Institution: Off
Daycare: Off
New: Off
Remodel: Off
Conversion: Off
NA No seats: Off
Area of Facility ft²:
Number of Floors:
Breakfast:
Lunch:
Dinner:
Refrigerator Storage:
Freezer Storage:
Dry Storage:
Identify the location and containers that will be used to store
bulk food products rice sugar etc:
List all foods that will be cooked and cooled:
1:
2:
3:
List all foods that will be cooked cooled and reheated:
1_2:
2_2:
3_2:
List all foods that will be hot held prior to service:
1_3:
2_3:
3_3:
undefined_6:
undefined_7:
Location:
undefined_8:
undefined_9:
Location_2:
Reduced Oxygen Packaging ROP Use of Additives to Render a Food
NonTCS Acidification Curing and: Off
If yes in addition to this application complete the Hazard Analysis
Critical Point Plan Review Application: Off
If yes complete the Request for Variance Form including the Granted
Variance Section of the form: Off
undefined_10: Off
undefined_11: Off
Ready to Eat Foods RTE eg salads cold sandwiches and raw molluscan
shellfish:
Produce:
Poultry:
Meat:
Seafood:
Yes_11: Off
Explain how the basement will be used for food preparation:
1_4:
2_4:
What is the capacity and location of the water heater:
Will an ice machine be installed: Off
If yes where:
Will the largest pot pan fit into each compartment of the
3compartment sink: Off
If No describe the cleaning method that will be used:
1_5:
2_5:
Describe the location type of device used for air drying clean
equipment:
1_6:
2_6:
Will the machine be equipped to automatically dispense detergents
and sanitizers: Off
undefined_14: Off
Visual: Off
Audible: Off
What type of sanitizer and the brand name will be used on food
contact surfaces:
Chlorine: Off
Quaternary: Off
If no where will employees store personal items:
Identify the storage location for poisonous or toxic materials
chemical storage:
Identify how grease will be disposed:
How often will the grease traps be cleaned:
Identify the location of grease storage containers:
REFUSE:
If yes describe where:
Identify how and where garbage cans and floor mats will be
cleaned:
undefined_18: Off
Name of company used for dumpster pickup:
Describe the surface and location where the dumpster garbage will
be stored outside:
Is there a Written Employee Health Policy for ALL Employees:
undefined_19: Off
WALLSGarbage Refuse Storage:
CEILINGGarbage Refuse Storage:
FLOORMop Service Sink:
WALLSMop Service Sink:
CEILINGMop Service Sink:
FLOORWare washing Area:
WALLSWare washing Area:
CEILINGWare washing Area:
FLOORWalkin Refrigerators Freezers:
WALLSWalkin Refrigerators Freezers:
CEILINGWalkin Refrigerators Freezers:
undefined_22: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow2:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow3:
undefined_23: Off
undefined_24: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow7:
undefined_25: Off
undefined_26: Off
undefined_27: Off
A copy of Certified Food Managers Certificate Allergy Awareness
Certificate Choke Save Training Certificate:
Certified Food Managers Certificate: Off
Allergy Awareness Certificate: Off
undefined_28: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow14:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow15:
undefined_29: Off
STATEMENT I:
Print Name:
Date Submitted:
Fee Received:
2_7: Off
3_4: Off
4A: Off
4B: Off
1_7:
2_8:
Custard:
undefined_34: Off
undefined_40:
Other_2:
If Frozen Yogurt is manufactured will it contain friendly cultured
bacteria live cultures Yes:
undefined_41: Off
Sources of Ingredients 1:
Sources of Ingredients 2:
Sources of Ingredients 3:
be used unless the importer has documentation to show that the
exporter is in compliance with 21 CFR Part 1210:
Yes Type of Machine: Off
No_27: Off
1_8:
2_9:
If No describe what will be used and how:
1_9:
2_10:
1_10:
2_11:
undefined_44:
How will the refrigerated and frozen product be delivered and
transported 1:
How will the refrigerated and frozen product be delivered and
transported 2:
undefined_45:
If transported how will the product temperature be monitored
1:
If transported how will the product temperature be monitored
2:
undefined_46:
How often will the surfaces and equipment be cleaned and
sanitized:
undefined_47:
What are the procedures for cleaning the equipment and surfaces and
what product will be used 1:
What are the procedures for cleaning the equipment and surfaces and
what product will be used 2:
undefined_48:
Name and Type of Sanitizer:
Completed Application for License to Manufacture Frozen Desserts
and or Ice Cream Mix: Off
Completed Food Establishment Plan Review and Food Establishment
Application for new food establishments only: Off
License fee of 500: Off
Equipment Specification sheets used in the process ie SoftServe
Machines etc: Off
For existing food establishments provide a sketch of the processing
area and or the placement of the: Off
STATEMENT I_2:
Catering is defined as Delivering AND Serving: Off
Will there be seating Yes: Off
No_33: Off
Applicants Name_3:
To Quality for a Food Establishment Permit an Applicant shall be an
Owner or an Officer of the Legal Ownership:
Phone Number_2:
Name of Emergency Contact Person:
affirm to comply with the MA Department of Public Health State
Sanitary Code:
Federal Identification Number:
undefined_55:
undefined_56:
Special Process Plan Review:
Risk Category 2:
Risk Category 3: