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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

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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.

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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.

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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.

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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.

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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

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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.

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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:__________

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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

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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

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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)

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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? ____________________________________________________________________________________________________________________________________________________________________________

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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.

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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.

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MENU EXAMPLE

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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:

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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:____________________________________