FOR BOARD OF HEALTH USE ONLY

Date Received Date Inspected Approved By Permit # Issued

____________ _____________ ______________________ ______________

Leicester Board of Health

Food Establishment Permit Application

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

1) Establishment Name:
2) Establishment Address:
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant Name & Title:
6) Applicant Address:
7) Applicant Telephone No: 24 Hour Emergency No:
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By: • An association • A corporation • An individual • A partnership • Other legal entity_______________		11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
12) Person Directly Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager etc.)
Name & Title:
Address:
Telephone No:	Fax:
Emergency Telephone No:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:	Fax:

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Food Establishment Information

14) Water Source: DEP Public Water Supply No: ( if applicable)					15) Sewage disposal:
16) Days and Hours of Operation:					17) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management: Required as of 10/1/2001in accordance with 105 CMR 590.003(A) Please attach copy of certificate.
19) Person Trained In Anti-Choking Procedures (if 25 seats or more): • Yes • No
20) Location: (check one) q Permanent Structure q Mobile		22) Establishment Type(check all that apply) q Retail ( Sq. Ft) q Food Service – ( Seats) q Food Service – Takeout q Food Service – Institution ( Meals/Day)				q Caterer q Food Delivery q Residential Kitchen for Retail Sale q Residential Kitchen for Bed and Breakfast Home q Residential Kitchen for Bed and Breakfast Establishments q Frozen Dessert Manufacturer
21) Length Of Permit: (check one) q Annual q Seasonal/Dates: ____________________ q Temporary/Dates/Time: _____________________		Other (Describe)
23) Food Operations: (check all that apply):	Definitions:			PHF – potentially hazardous food(time/temperature controls required) Non-PHFs – non- potentially hazardous food (no time/temperature controls required) RTE – ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
q Sale of Commercially Pre-Packaged Non-PHFs			q PHF Cooked To Order		q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service.
q Sale of Commercially Pre-Packaged PHFs			q Preparation Of PHFs For Hot And Cold Holding For Single Meal Service.		q PHF and RTE Foods Prepared For Highly Susceptible Population Facility
q Delivery of Packaged PHFs			q Sale Of Raw Animal Foods Intended to be Prepared by Consumer.		q Vacuum Packaging/Cook Chill
q Reheating of Commercially Processed Foods For Service Within 4 Hours.			q Customer Self-Service		q Use Of Process Requiring A Variance And/Or HACCP Plan (including bare hand contact alternative, time as a public health control)
q Customer Self-Service Of Non-PHF and Non-Perishable Foods Only.			q Ice Manufactured and Packaged for Retail Sale		q Offers Raw Or Undercooked Food Of Animal Origin.
q Preparation Of Non-PHFs			q Juice Manufactured and Packaged for Retail Sale		q Prepares Food/Single Meals for Catered Events or Institutional Food Service
To be completed by the Board of Health Total Permit Fee:________________ Payment is due with application Other (Describe):			q Offers RTE PHF in Bulk Quantities
			q Retail Sale of Salvage, Out-of Date or Reconditioned Food

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

24) Signature of Applicant: _________________________________________________________

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.

25) Social Security Number or Federal ID: _____________________________________________

26) Signature of Individual or Corporate Name: _________________________________________