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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):
Email address:
4. Establishment Phone #:
5. Applicant Name & Title:
6. Applicant Address:
7. Applicant Phone # 24 Hour Emergency #:
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: Email address:
Emergency Phone #:
13. Water Source (town or well water)
14. Sewage Disposal: □ Title 5 system □ Internal Grease
□ Grease trap interceptor
Town of Brewster
2198 MAIN STREET Health Department
BREWSTER, MASSACHUSETTS 02631-1898
Amy L. von Hone, R.S., C.H.O. Director
PHONE: 508.896.3701 EXT. 1120
FAX: 508.896.4538 Sherrie McCullough, R.S.
brhealth@brewster-ma.gov Assistant Director
WWW.BREWSTER-MA.GOV Tammi Mason
Senior Department Assistant
15. Days and hours of operation:
16. # of Food employees:
17. Name of Person in Charge Certified in Food Protection Management:
18. Person trained in Anti Choking procedures (if 25 seats or more):
19. Name of person with Allergen Awareness Certification
20. Location (check one):
□ Permanent structure
□ Mobile
□ Other
□ Leased/shared commercial
kitchen
21. Establishment type (Check all that apply)
□ Retail (sq. ft.) □ Residential Kitchen: B&B Operations
□ Food Service (seats) # of seats ___ □ Residential Kitchen: Cottage Food
□ Food Service – Takeout Operation
□ Food Service – institution □ Frozen Dessert Manufacturer
# of meals___ # of days___
□ Caterer
□ Food Delivery
Other (describe):
22. Length of Permit
□ Annual
□ Seasonal/Dates
23. Food Operations: (Check
all that apply)
Definitions: TCS food – Time/temperature control for safety food – food that requires
time/temperature control for safety to limit pathogenic microorganism growth or toxin
formation; Non-TCS food – non potentially hazardous food (no time/temperature
controls); RTE – ready to eat foods (Ex. Sandwiches, salads, muffins which need no further
processing)
□ Sale of Commercially pre-
packaged Non – TCS food
□ TCS Cooked to order □ Hot TCS food cooked and cooled or hot held
for more than a single meal service
□ Sale of Commercially pre-
packaged TCS food
□ Preparation of TCS food for hot and
cold holding for single meal service
□ TCS food and RTE foods prepared for highly
susceptible population facility
□ Delivery of packaged TCS
food
□ 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-TCS food and non-
perishable foods only
□ Ice manufactured and packaged for
retail sale
□ Offers raw or undercooked food of animal
origin
□ Preparation of non-TCS
food
□ Juice manufactured and packaged
for retail sale
□ Prepares food/single meals for catered events
or institutional food service
□ Offers RTE TCS food in
bulk quantities
□ Retail sale of salvage, out -of –date
or reconditioned food
□ Other (describe):
Total permit fee: ____________________Payment is due with application
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 application law. I have been instructed by the
Board of Health on how to obtain copies of 105 CMR 590.000 and the 2013 Federal Food Code.
24. Signature of applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to the best of my knowledge and belief,
have filed all state tax returns and paid taxes required under law.
25. Signature of Individual or Corporate name: