Updated 2017_JF Page 1
FOOD ESTABLISHMENT PLAN REVIEW PACKET
Establishment Name: __________________________________________________
Pages:
1. Food Establishment Plan Review Process Checklist………………………………………......2
2. Food Establishment Permit Definitions……………………………………………………….3 - 5
3. Taunton Board of Health Permit Fees ………………………………………………………..6
4. Billing Policy…………………………………………………………………………………7
5. Food Establishment Plan and Specification Review…………………………………………8 - 9
6. Specifications:……………………………………………………………………………….10 - 14
(a) Finish schedule
(b) Insect and Rodent Harborage
(c) Garbage and Refuse Inside
(d) Garbage and Refuse Outside
(e) Plumbing
(f) Handwashing Stations
(g) Water Supply
(h) Sewage Disposal
(i) Employee Restrooms/dressing rooms
(j) Storage and Laundry
(k) Exhaust Systems
(l) Sinks
(m) Ware-washing Facilities
7. Appendices / Examples:…………………………………………………………………...15 - 16
(a) Floor Plan
(b) Final Menu
8. Application for Food Establishment Service Permit………………………………………17 - 18
Taunton Board of Health 45 School Street
Taunton, MA 02780-3212 _______________________________________________________________________________________________________
P: 508-821-1400 F: 508-821-1403
BOARD MEMBERS Dr. BRUCE E. BODNER
Dr. THADDEUS FIGLOCK
Dr. JOSEPH F. NATES
HEATHER L. GALLANT, MPH, RS, CHO
EXECUTIVE DIRECTOR
ADAM S. VICKSTROM
ASSISTANT EXECUTIVE DIRECTOR
Updated 2017_JF Page 2
FOOD ESTABLISHMENT PLAN REVIEW PROCESS CHECKLIST
Submit Floor Plans. Please include Grease Trap and Second Containment Plans . (i.e. Blue prints, sketch,
etc.)
See example on page 14.
Submit a Full Menu. Include all food products and beverages that you plan to serve.
See example on page 15.
Submit Plan Review Fee: $50.00 *Please make the check payable to the “City of Taunton.”
If the name of the establishment is not on the check please place the name in the note section, as well as,
“Food Establishment Plan Review.”
Submit a completed Food Establishment Plan Review Application.
Ensure the attached Food Establishment Permit Application is filled out.
The Health Department will complete a review of the plans and all other information within 30 days.
Food establishment review plans must be approved by the Sanitary Inspector before any work or construction
may begin.
Complete any additional Food Service Permit Application(s) you may require. (i.e. Retail Food, Milk, Frozen
Dessert, etc.)
Submit a separate check for the appropriate Food Service Permits. *Confirm appropriate fee with the Clerk or
Sanitary Inspector before submitting check.
See attached Definition Page – Pgs.3-5 and Permit Fee Page – Pg.6
Submit copies of Food Protection Manager & Allergen Awareness Training Certificates.
Submit a copy of a Choke Saving (AED / CPR) Certification - *Establishment who have 25+ seats.
Submit the HAZARDOUS MATERIALS PLAN REVIEW. (i.e. Batteries, chemicals, hairspray, etc. sold)*Fee
based on how many classifications your establishment is under and square footage.
A separate check will be needed and made payable to “The City of Taunton.”
Once the BOH has received and reviewed all of the required information; we issue a conditional letter (checklist
of items needed prior to inspection.) Once you have received the letter, please call the BOH to set up a date and
time for a pre-operation inspection. If no issues or concerns during the pre-operation inspection, the BOH then
issues the permit on site. If there are any issues or concerns arise, they must be corrected and another inspection
must be conducted before issuing a permit to operate.
THE ISSUANCE OF OTHER REQUIREMENTS:
Check with all other applicable City Departments for their appropriate requirements. (i.e. City Hall,
Building, Fire, Zoning etc.)
*** NOTE: This plan review packet applies to Board of Health procedures only.
Submit a ZONING COMPLIANCE LETTER from the City Planner.
Check attached Fats Oils Grease (FOG) Regulation to ensure compliance with your establishment. NOTE: The
secondary containment requirement is a local Board of Health and Department of Public Works
requirement and not a MA state plumbing code requirement in some cases. For questions on compliance
check with sanitary inspector who oversees the FOG regulation by calling the Board of Health office.
Updated 2017_JF Page 3
Food Establishment Permit Definitions
*NOTE: These definitions should be used in conjunction with the permit fee schedule. (Provided after this section.)
Food Service: Where any food product is heated, opened, sliced or prepared
in any way.
Retail: Products are packaged by a licensed manufacturer and remains intact until
opened by the consumer. Any other food item (i.e. hot dogs, popcorn, etc.) or
beverage items (i.e. slush drinks, coffee) that are provided will require a Food
Service permit and will require that the establishment have a 3-bay sink to
properly wash, rinse, and sanitize all food contact equipment and grease traps
/ interceptors in accordance with the City of Taunton FOG (Fats, Oils, &
Grease) Regulations.
Catering: Preparation and transportation of meals intended for individual portion
service or a company preparing food in a location other than their permitted
establishment.
Mobile: Self-propelled vehicle-mounted food establishment or push cart.
Milk: Any establishment that sells milk as retail or that uses milk for coffee service or
as part of any food preparation process.
Potentially Hazardous Food (also known as TCS – Time Control for Safety foods): Foods that need time and
temperature control to limit bacteria growth. Examples include animal food (a food of animal origin) that is raw
or heat-treated, as well as, items such as milk and dairy products, meat, fish, baked potatoes, tofu or other soy
protein products, sliced melons, cut tomatoes, cut leafy greens, shell eggs, poultry, shellfish and crustaceans,
cooked rice, cooked beans, and cooked vegetables, sprouts and sprout seeds, and garlic-in-oil mixtures that are
untreated.
Non Potentially Hazardous Foods: Shelf-stable foods that do not require time and temperature control to
limit bacteria growth for human consumption. Examples include whole uncut fruit and vegetables, packaged
cookies and dry goods, jams, jellies, candy, and dried mixes. Any item that does not meet the definition of
potentially hazardous food.
Sale of Commercially Pre-Packaged Non-PHF’s: Packaged, shelf-stable, non-potentially hazardous food at the
retail level in original packaging. Products must be obtained from an approved source and meet all current labeling
requirements. Examples including baked goods, granola, commercial canned goods, candy bars, potato chips, etc.
Sale of Commercially Pre-Packaged PHF’s: Packaged, potentially hazardous food at the retail level in original
packaging. Products must be obtained from an approved source and meet all current labeling requirements. These
foods must also require time and temperature control for safety. No food preparation is conducted on the premises.
Examples include meat, milk, cheese, sandwiches, burritos, salads etc.
Delivery of Packaged PHF’s: The carrying and turning over of goods to a designated recipient or recipients.
These goods include potentially hazardous food at the retail level. Products must be obtained from an approved
source and meet all current labeling requirements. These foods must also require time and temperature control for
safety. Examples include packaged meat, seafood, specialty items requiring HACCP Plan – smoked salmon and
caviar.
Reheating of Commercially Processed Foods for Service within 4 hours: Food that is commercially prepared
(often through processing) to improve ease of consumption. Such food is usually ready to eat without further
preparation and is reheated to a proper internal temperature of 165°F and served within 4 hours.
Updated 2017_JF Page 4
Customer Self-Service of Non PHF and Non-Perishable Foods Only: The serving of oneself in a restaurant,
shop, gas station, or other facility, without the aid of a waiter, clerk, attendant, etc. with foods that do not need
refrigeration and or support the growth of bacteria. Examples include oatmeal, dried fruits and nuts, packaged
snacks, single serving soups and noodles, coffee and soft drinks.
Preparation of Non-PHF’s: Thawing, cooking, cooling and reheating of foods that do not need time and
temperature control for safety. Examples include waffles, rolls, fruited gelatin, fruit crisp, bagels, and biscuits.
Offers RTE PHF in Bulk Quantities: Large quantities of food that does not require cooking; or food that has
already been cooked and held properly. These foods need time and temperature control for safety. Examples
include deli meat, salad, sandwiches, cheese, and cut fruits and vegetables are a few of the many food items that
you do not need to cook before use.
PHF Cooked to Order: Prepared specifically when someone requests the item, so that the item can be customized
as desired by the person who requested it. These foods need time and temperature control for safety. Examples
include burgers or sandwiches, which are made to order; the food has been cooked, and items are warm, but the
final product is not assembled until the customer has actually ordered it.
Preparation of PHF’s for Hot and Cold Holding for Single Meal Service: These foods need time and
temperature control for safety. Hot holding of PHF foods must be 140°F or higher. Cold holding of PHF foods
must be at 41°F or lower. These foods are served during one meal period only. An example would be a brunch
buffet.
Sale of Raw Animal Foods Intended to be prepared by Consumer: The sale of raw animal foods including
eggs, fish, meat, poultry, and foods containing these raw animal foods. These items must be purchased by a
reputable supplier then purchased by the consumer to be prepared at a later time.
Customer Self-Service: The serving of oneself in a restaurant, shop, gas station, or other facility, without the aid
of a waiter, clerk, attendant, etc. with foods that do not need refrigeration and or support the growth of bacteria.
Examples include coffee, soft serve beverages, hot dogs, donuts, salad bar, and buffets.
Ice Manufactured and Packaged for Retail Sale: Manufacturers of ice that produce, hold, and transport ice
under clean and sanitary conditions, and use water that is safe and sanitary. Packaged ice labels must meet FDA
food labeling requirements.
Juice Manufactured and Packaged for Retail Sale: Manufacturers of liquid expressed or extracted from one or
more fruits or vegetables, purées of the edible portions of one or more fruits or vegetables, or any concentrate of
such liquid or purée and then bottled for retail sale. Bottle labels must meet FDA food labeling requirements. Must
meet FDA Juice HACCP regulations.
Retail Sale of Salvage, Out-of-Date or Reconditioned Food: Any food establishment that buys and sells, or
warehouses salvaged food. Foods that restaurants or retailers weren’t able to sell are donated to charity – for
example, when a product’s “sell-by” date has passed or a can’s label is torn or missing. An expired sell-by date
doesn’t necessarily mean that a food has gone bad or is unsafe – when the food has been handled safely.
“Reconditioning" means any appropriate process or procedure by which distressed food can be brought into
compliance with all Department requirements, making it suitable for consumption and use by humans.
Hot PHF Cooked and Cooled or Hot Held for more than a Single Meal Service: Foods that require time and
temperature control for safety for more than one meal period. An example includes a hot buffet line where soup is
cooked then hot held for lunch and dinner, and/or cooked and later properly cooled to be put away for the next day
for meal service.
Updated 2017_JF Page 5
PHF and RTE Foods Prepared for a Highly Susceptible Population Facility: Preparing potentially hazardous
foods that require the process of thawing, cooking, cooling, and/or reheating of foods that need time and
temperature control for safety. Ready to eat foods that do not require any further processing and are handled safely.
“Highly susceptible population" means people who are more likely than others in the general population to
experience foodborne disease because they are:
Immunocompromised; preschool age children, pregnant, or the elderly; and
Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as
a child or adult day care center, kidney dialysis center, hospital or nursing home, or nutritional or socialization
services such as a senior center.
Vacuum Packaging / Cook Chill: “Vacuum packaging” is the process in which air is removed from a package
of food and the package is hermetically sealed so that a vacuum remains inside the package, such as sous vide.
“Cook Chill” is the process in which foods that are pre-cooked and chilled, then later reheated. This requires a
variance.
Use of a process requiring a Variance and/or HACCP Plan: Establishments that use Time as a Public Heath
Control, and/ or any special processes such as Rice Acidification, packaging fresh juice on-site for sale at a later
time unless the juice has a warning label, smoking food as a way to preserve it, using food additives or adding
components such as vinegar as a way to preserve (i.e. jarring and canning items), curing food, custom-processing
animals for personal use, packaging food using reduces-oxygen packaging (ROP) method – this includes MAP,
vacuum-packed, and sous vide food, sprouting seeds or beans, and offering live shellfish from a display tank. You
must apply for a variance with the local board of health and submit a HACCP plan. The plan must account for any
food safety risks related to the way you plan to prep the food item.
Offers Raw or Undercooked Food of Animal Origin: Establishments that serve animal origin items without
cooking these items at all and served to the consumer in a raw state. Examples of food include sushi, steak tartar,
and cerviche.
Prepares Food/Single Meals for Catered Events or Institutional Food Service: Food prepared, thawed, cooked,
and properly held in a licensed food establishment which then is delivered to an offsite special event and/or an
institution that the food service is being provided for one meal period only; such as prisons, hospitals, colleges,
primary and secondary schools, etc. An example includes a main school commissary preparing and cooking all the
meals for the school district, properly handling, packaging, and holding the food, then shipping to each school for
a specific meal period.
Updated 2017_JF Page 6
TAUNTON BOARD OF HEALTH PERMIT FEE SCHEDULE:
*Fees to be paid per year
TYPE OF ESTABLISHMENT: FEE AMOUNT:
Food / Retail Establishment Plan Review $50.00 Food Establishment Permit: 0 – 50 Seats 51 – 100 Seats 101 – 150 Seats 151 – 300 Seats
$150.00 $200.00 $250.00 $300.00
Milk Permit $25.00 Frozen Dessert Permit $50.00
Mobile/Canteen Food Permit (per unit) $150.00 per unit Mobile / Canteen Service Centers Permit $100.00
Catering Establishment Permit $150.00
Catering Delivery Vehicle (per unit) $25.00 *Add another $25.00 for each individual vehicle.
Retail Food Permit $150.00
Supermarket Permit $250.00 *Add another $100.00 if food service is applicable.
Bakery Permit $100.00
Residential Kitchen Permit $100.00 Church Kitchen Permit $30.00
Nursing Home Kitchen Permit $100.00 Pre-Schools / Nursery Kitchen Permit $100.00
Bottling Establishment $200.00
Updated 2017_JF Page 7
Billing Policy:
Annual licenses, permits or fees or renewals of same which require billing by the Taunton Board of Health, shall be sent to the applicant thirty (30) days prior to the anniversary date prescribed under Massachusetts General Law. The license or permit will be issued on the thirtieth (30th) day if a valid check payable to the “City of Taunton” has been received by the last day. If the valid check has not been received within the proper time frame, the license or permit will not be issued for that year, or suspended if the check is found to be invalid after the thirty day time frame. The business or commercial activity authorized under the license, permit or fee shall be terminated by the Board of Health for the remainder of the year, or until such time, as a new application with valid check has been submitted to the Board of Health, which will further require a special inspection of the business premises, commercial vehicle or site by an inspector of the Board of Health. After these requirements haven been met, the appropriate license, permit or certification will be issued and the business or commercial activities may resume.
In cases where a bad check is received and found to be invalid for insufficient funds, a replacement payment shall be required by bank certified check or money order only. In addition the City of Taunton Treasure’s Office requires a $25.00 surcharge. There will be no exceptions of this policy.
Your cooperation and assistance is required to avoid untimely delays in the operation of your business activities.
Updated 2017_JF Page 8
FOOD ESTABLISHMENT PLAN AND SPECIFICATION REVIEW
Date:___________________________
Please PRINT all requested information below.
This Food Establishment Plan and Specification Review is a result of a:
Check all that apply:
New construction project
Remodel project
Conversion project
New operation that is being added ________________________________________________________________________________________
Name of Establishment:____________________________________________________________________
Establishment Address:____________________________________________________________________
Establishment Phone Number:______________________________________________________________
Hours of Operation: Monday____________ Friday_____________ Tuesday____________ Saturday___________ Wednesday__________ Sunday____________ Thursday____________
Months of Operation:_____________________________________________________________________ ________________________________________________________________________________________
Name of Owner:__________________________________________________________________________
Owner’s Mailing Address:__________________________________________________________________
Owner’s Phone Number:___________________________________________________________________ ________________________________________________________________________________________
Name of Applicant (*If different than Owner):__________________________________________________
Applicant’s Mailing Address:________________________________________________________________
Applicant’s Phone Number:_________________________________________________________________
Title/Relationship to Establishment (i.e.: person in charge, manager ect.): ________________________________________________________________________________________
FOOD ESTABLISHMENT INFORMATION
Meals to be served (approximate number):
Breakfast:__________ Lunch:_____________ Dinner:____________
Structural / Building Information: Number of floors:__________
Updated 2017_JF Page 9
Square footage:___________
Customer Capacity Information (if applicable): Number of seats:__________
Number of beds:__________
Please enclose the following documents:
Site plan showing location of business in building, location of building on site, streets and location of any facility (i.e. dumpsters, wells, septic systems.)
Manufacturer’s Specification Sheets for each piece of equipment (cut sheets.)
FLOOR COVING WALLS CEILING
Kitchen Area / Back of House
Bar
Warewashing Area ( ie. 3 comp sink, dishwasher)
Dry Food Storage
Other Storage:
Storage Area #1 Location:___________________
Storage Area #2 Location:___________________
Storage Area #3 Location:___________________
Rest Rooms
Employee Dressing Rooms
Inside Garbage/Refuse Storage
Mop Service Sink Area
Walk-in Refrigerator(s)
Walk-in Freezer (s)
Customer Areas
Updated 2017_JF Page 10
Floor Plan of Food Establishment. (i.e. blue prints, hand drawn.)
Proposed Menu (including off-site and banquet menus.)
SPECIFICATIONS:
A. Finish Schedule:
Indicate the type of materials to be used (i.e.: quarry tile, stainless steel, sealed concrete, terrazzo, ceramic tile, durable grade of plastic.)*Please write N/A if not applicable.
B. Insect and Rodent Harborage:
1. Are all outside doors self-closing with rodent and insect proof flashing?
Yes No
2. Are screen doors provided on outside doors for use in warm weather?
Yes No Not Applicable
3. Do all operable windows have a minimum of 16 mesh to the inch screening?
Yes No Not Applicable
4. Are all pipes, electrical conduit cases, ventilation system exhausts and intakes sealed and/or covered/protected?
Yes No Not Applicable
5. Are air curtains used?
Yes No If Yes, where?_____________________
C. Garbage and Refuse Inside:
1. What kind of refuse containers will be used inside? __________________________________________________________________________________________________________________________________________________________________________
2. Will refuse be stored inside?
Yes If Yes, where?________________________________________________________________
No
D. Garbage and Refuse Outside:
1. Will a dumpster be used?
Yes Number:____________ Frequency of Pick-up:_________________________________________________________ Contractor Used:_____________________________________________________________
No
2. Will refuse containers be stored outside?
Yes No
Updated 2017_JF Page 11
3. Describe the surface on which the dumpster/cans/compactor are to be stored?
*NOTE: All outside refuse storage containers must be in an enclosed area and stored on or above a smooth surface that is made of a nonabsorbent material that is in good repair.
Description:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E. Plumbing: *Please contact the Plumbing Inspector at the Building Department with regards
to any and all plumbing code questions.
1. Are there grease traps provided at all warewashing and food preparation sinks?
Yes No
F. Handwashing Stations:
1. Soap dispensers (wall mounted or individual pump dispensers) location of each:
(a)_______________ (d)_______________ (b)_______________ (e)_______________ (c)_______________ (f)_______________
2. Hand drying facilities (paper towels or air blower) location of each:
(a)_______________ (d)_______________ (b)_______________ (e)_______________ (c)_______________ (f)_______________
3. Hot and cold water confirmed at each hand wash station?
Yes
No If No, indicate location and problem:___________________________________
G. Water Supply:
1. Type of Water Supply:
Public
Private If Private, has source been approved?
Yes: please attach copy of written approval.
No
Pending
2. Ice Production:
Purchased Commercially
Made on Premises
If produced on premises by machine; are specifications enclosed? Yes No
H. Sewage Disposal:
1. Type of sewage disposal:
Municipal Sewer
Private Disposal System (i.e. septic system)
Updated 2017_JF Page 12
2. Has private disposal system been approved?
Yes
No
Pending
Not Applicable
I. Employee Restrooms and Dressing Rooms:
1. Will employees share restrooms with customers or will employees have their own restrooms?
Shared Employees only
2. Describe storage area for employees’ personal belongings (coats, purses, etc.):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
J. Storage and Laundry:
1. Describe storage facilities that are made available for the separate storage of all toxics, chemicals and cleaning supplies:_______________________________________________________
2. Are laundry facilities located on the premises?
Yes If Yes, what will be laundered?__________________________________________________
No
3. Is location physically separated from food preparation and warewashing areas?
Yes No
4. Location of clean linen storage:_____________________________________________________
5. Location of soiled linen storage:___________________________________________________
K. Exhaust Systems:
1. Please list and indicate purpose of all ventilation systems, both general smoke/grease filter type:
(a)_______________________________________________________________________
(b)_______________________________________________________________________
(c)_______________________________________________________________________
(d)_______________________________________________________________________
L. Sinks:
1. Is a separate mop sink present?
Yes
No If No, please describe facility for cleaning of mops and other cleaning equipment? ____________________________________________________________________________________________________________________________________________________________________________
Updated 2017_JF Page 13
2. Is a separate food preparation sink made available?
Yes No
3. Is a separate handwash sink present in the food preparation area?
Yes No
M. Ware-washing Facilities:
1. Is there a three (3) compartment sink (mandatory) provided for warewashing?
Yes No
2. Three compartment sink information:
Does the largest pot/pan fit in each sink? Yes No
Are there drain boards on each end? Yes No
3. What type of sanitizer is used?
Chlorine/Bleach
Quaternary ammonium compound (QAC)
Iodine
4. Are the appropriate test strips on-hand? Yes No
5. If a Dishwasher is to be used in addition to a three compartment sink, please indicate the type of sanitizing cycle used:
High Temperature Final Rinse: Temperature of wash water:____________________________________ Temperature of final rinse:_____________________________________
Proper dishwasher temperature labels used: Yes No
Heat Booster provided: Yes No
Automatically Dispensed Chemical Sanitizer: Type of chemical sanitizer used:_________________________________
Proper test strips on-hand: Yes No
No Dishwasher
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 Taunton Board of Health may nullify this approval.
Applicant’s Signature:______________________________________________________________________ Applicant’s Printed Name:__________________________________________________________________ Date:_________________________
Approval of these plans and specifications by this Health Department does not indicate compliance with any other code, law or regulations that may be required; federal, state or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A pre-opening inspection of the establishment with equipment will be necessary to determine if it complies with the local and state laws governing food service establishments.
Updated 2017_JF Page 14
APPENDICES/ EXAMPLES
(a) Floor Plan
(b) Final Menu
***The Taunton Board of Health does not intend to recommend or represent
any company or piece of equipment shown on the following pages.
Updated 2017_JF Page 15
Updated 2017_JF Page 16
MENU EXAMPLE
Updated 2017_JF Page 17
Taunton Board of Health Food Establishment Permit Application
(Application must be submitted at least 30 Days Prior to Plan Review.)
Establishment Name:
Establishment Address:
Establishment Mailing Address (*If different):
Establishment Telephone Number:
Applicant Name & Title:
Applicant Mailing Address:
Applicant Telephone Number:
*EMERGENCY CONTACT TELEPHONE NUMBER:
Owner Name & Title (*If different from applicant.)
Owner Mailing Address (*If different from applicant.)
Establishment Owned By:
An Association
A Corporation
An Individual
A Partnership
Other Legal Entity:_________________
If a corporation or partnerships please provide the give name, title, and mailing address of officers or partner. Name: Title: Mailing Address:
Person Directly Responsible for Daily Operations: (Owner, Person in charge, Supervisor, Manager, etc.)
Name & Title:
Mailing Address:
Telephone Number:
Fax Number:
*EMERGENCY Telephone Number:
District or Regional Supervisor: (If Applicable)
Name & Title:
Mailing Address:
Telephone Number: Fax Number:
*EMERGENCY Telephone Number:
Water Source: DEP Public Water Supply No: (If Applicable)
Sewage Disposal:
Days and Hours of Operation: Number of Seats:
Number of Food Employees:
Updated 2017_JF Page 18
Food Establishment Information:
Name of Person in Charge in Food Protection Management: Required as of 10/2010 in accordance with 105 CMR 590.003 (A). *Please attach a copy of the certificate.
Name of Person in Charge in Allergen Awareness Training: Required as of 10/2010 in accordance with 105 CMR 590.009 (H). *Please attach a copy of the certificate.
Person Trained in Anti-Choking Procedures (*If 25 and more seats) : Required as of 10/2010 in accordance with 105 CMR 590.009 (E). *Please attach a copy of the certificate.
Location (*Check One):
Permanent Structure
Mobile
Length of Permit: (*Check One):
Annual
Seasonal – Dates of Operation:_______________________________
Temporary– Dates of Operation:______________________________
Establishment Type: (*Check all that apply)
Retail: # of Square Feet:_____________ Residential Kitchen / Establishment
Food Service: # of Seats:_____________ Residential Kitchen for Retail Sale
Food Service – Institution - # of Beds:___________ Residential Kitchen for Bed & Breakfast Home
# of Meals / Day:__________ Food Processing / Manufacturer
Caterer: # of Vehicles:______________ School/Nursery/Daycare
Mobile / Canteen Truck Bakery
Church Kitchen Supermarket
Liquor Store Variety Store
OTHER: (*Describe) __________________________________________________________________________________________________ Additional Permits: (*Check all that apply)
Milk / Cream (Used or Sold) Frozen Dessert Machine (Soft Serve or Yogurt)
Food Operations: (*Check all that apply):
Definitions: PHF – Potentially Hazardous Foods (*Time/Temp Controls Required.) NON-PHF’s: Non-Potentially Hazardous Food (No Time/Temp Controls Required.) RTE – Ready-To-Eat Foods (i.e. Sandwiches, salads, muffins; no further processing needed.)
Sale of Commercially Pre-Packaged Non-PHF’s
PHF Cooked to Order
Hot PHF Cooked and Cooled or Hot Held for more than a Single Meal Service
Sale of Commercially Pre-Packaged PHF’s Preparation of PHF’s for Hot and Cold Holding for Single Meal Service
PHF and RTE Foods Prepared For Highly Susceptible Population Facility
Delivery of Packaged PHF’s Sale of Raw Animal Foods Intended to be Prepared by Consumer
Vacuum Packaging / Cook Chill
Reheating of Commercially Processed Foods for Service within 4 hours
Customer Self-Service Use of Process requiring a Variance and/or HACCP Plan (including Bare Hand Contact Alternative, time as a Public Health Control)
Customer Self-Service of Non PHF and Non-Perishable Foods Only
Ice Manufactured and Packaged for Retail Sale
Offers Raw or Undercooked Food of Animal Origin
Preparation of Non-PHF’s Juice Manufactured and Packaged for Retail Sale
Prepares Food/Single Meals for Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out-of-Date or Reconditioned Food
OTHER:
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 590.00 and all other applicable laws. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.00 and the Federal (FDA) Food Code.
Signature of Applicant:___________________________________________________________________________________
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law.
Social Security Number or Federal ID:_________________________________________
Signature of Individual or Corporate Name:____________________________________