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Home My Public Portal AboutFood Establishment Plan Review Application - Change of Menu, Equipment, Operations, or Minor Renovations fillable_202009040840447168 TOWN OF WATERTOWN Board of Health Administration Building 149 Main Street Watertown, MA 02472 Phone: 617-972-6446 Fax: 617-972-6499 www.watertown-ma.gov Food Establishment Plan Review Application CHANGE IN MENU, EQUIPMENT, OPERATIONS, OR RENOVATIONS Name of Establishment: Address of Establishment: 105 CMR 590.011 requires the Board of Health to deny or grant approval of food establishment plans within thirty (30) days upon submission of said plans. This thirty-day (30) time period begins when a complete application when all the paperwork has been submitted to the Health Department. I, __________________________________, have read and understand the contents/requirements of this application packet and agree to the provisions listed above and contained within. Date__________________________ NO CHANGE IN MENU, EQUIPMENT, OPERATIONS, OR RENOVATION IS PERMITTED IN FOOD ESTABLISHMENTS UNLESS APPROVED BY THE HEALTH DEPARTMENT For Office Use Only:  Application Accepted by Health Department Date:  Initial Review Date: Complete / Incomplete Application  Application Resubmitted Date: Complete Application  Application Approval Date: Reviewer’s Signature: Watertown Health Department Food Plan Review Application – Change in Menu, Equipment, or Operations Page 2 | 5 Required Information to begin Plan Review Process: 1. Completed Food Establishment Plan Review Application for Change in Menu, Equipment, Operations, or Renovation. 2. Include the following items with the completed application: Floor plan drawn to scale shows location of all equipment to determine food flow Site plan, outside of establishment showing location of all equipment & refuse storage Manufacturer’s specification sheet(s) and equipment key for all equipment, all equipment must be NSF, AMSE, or ANSI certified Menu with Consumer Advisory and Food Allergen Awareness, include all new proposed menu items Check for plan review fee (non-refundable) made out to “Town of Watertown” - Food Plan Review Fee for Change in Menu, Equipment, or Operations $ 50.00 - Food Plan Review Fee for Major Renovations $100.00 3. Letter from Health Department approving the submitted application for change in menu, equipment, or operations. The letter will allow for change in menu plan, equipment, or operations. No menu changes, equipment changes, or operations changes are allowed without this letter. Please call Chief Environmental Health Officer, with questions: 617-972-6446. *Copies of Town regulations may be acquired at the Watertown Health Department & the Town Clerk’s Office. A preoperational inspection of the proposed equipment, menu changes, or operations will be necessary to determine if it complies with the local and state laws governing food service establishment. TOWN OF WATERTOWN Board of Health Administration Building 149 Main Street Watertown, MA 02472 Phone: 617-972-6446 Fax: 617-972-6499 www.watertown-ma.gov PLAN REVIEW APPLICATION FOR CHANGE OF MENU, EQUIPMENT, OPERATIONS, OR RENOVATION 1) Name of Establishment: Date: 2) Establishment Address: 3) Establishment Telephone: Fax: 4) Mailing Address (if different): 5) Name & Title of Applicant: Email: 6) Address of Applicant: Telephone: 7) Name of Owner (If different from applicant): Email: 8) Address of Owner (If different from applicant): 9) Corporate or Partner Name, list information below: Name Title Home Address Telephone 10) Person(s) directly responsible for daily operations: Name & Title Telephone Email Address 24 hr. Emergency Telephone 11) Name of Certified Food Protection Manager: (attach copy of certificate) 12) Employee(s) trained in Allergen Awareness: (attach copy of certificate) 13) Employee(s) trained in Anti-Choking Procedures (if 25 seats or more): Yes No (attach copy of certificate) 14) Type of Business (check all that apply): Permit Type Fee Permit Type Fee Food Service 0-99 seats $ 200.00 Place of Worship and/or Function Hall $ 75.00 Food Service greater than 100 seats $ 350.00 Bakery $ 200.00 Small Pre-Packaged Non-Potentially Hazardous Foods $ 50.00 Catering Establishment $ 200.00 Retail Food less than 10,000 SQ FT $ 200.00 Additional Catering or HACCP Plan with other license fee $ 50.00 Retail Food greater than 10,000 SQ FT $ 450.00 Frozen Dessert Machine $ 50.00 Residential Kitchen $ 100.00 Frozen Dessert Manufacturer $ 200.00 15) Days and Hours of Operation: 16) Meals to be served (check all that apply): Breakfast Lunch Dinner 17) Number of Square Feet: Number of Seats: Watertown Health Department Food Plan Review Application – Change in Menu, Equipment, or Operations Page 4 | 5 18) Number of Staff (Maximum per shift): Number of Food Employees: 19) Check which applies: Permanent Structure Mobile 20) Length of Permit (check which applies): Annual Seasonal, write dates of season: 21) Specify Change In Menu, Equipment or Operations. Indicate type of proposed equipment, location of equipment. Use back page of this sheet if necessary. 22) Food Operations (check all that apply) Retail Sale of Commercially Pre-packaged Non-PHF’s Retail Sale of Commercially Pre-packaged PHF’s Preparation of PHF’s for eat in or take out (CFPM required) Offers RTE PHF in Bulk Quantities for catering pick up (CFPM required) PHF’s Cooked to Order or Served Raw of Undercooked (CFPM and Consumer Advisory required) Preparation of Food/Single Meals for Catered Events (CFPM required) Preparation of Non-PHF’s (coffee, hot dogs) Manufacture Frozen Dessert (CFPM required) Type of Operation requiring a Board of Health Variance and/or HACCP Plan approval: Use of unpasteurized shell eggs prepared for highly susceptible population (variance & HACCP Plan required) Use food additives for preservation (i.e. acidification of sushi rice) (variance & HACCP Plan required) Smoking for preservation (variance & HACCP Plan required) Curing (variance & HACCP Plan needed) Custom processing of animals (variance & HACCP Plan required) Molluscan shellfish tanks (variance & HACCP Plan required) Reduced oxygen packaging with barriers – ROP or vacuum packaging (variance & HACCP Plan required) Time as a Public Health Control (variance & HACCP Plan required) Preparing and serving raw molluscan shellfish (HACCP Plan required) Definitions: PHF – potentially hazardous food (time/temperature controls required) Non-PHF – non-potentially hazardous food (no time/temperature controls required) RTE – ready-to-eat foods (ex. sandwiches, salads, muffins, French fries. etc. which need no further processing) Highly Susceptible Population (HSP) - A group of persons who are more likely than other populations to experience food borne disease because they are immune-compromised, or older adults in a facility that provides health care or assisted living services, such as a hospital or nursing home, or children in day care or elementary school. CFPM – Certified Food Protection Manager Consumer Advisory – Written information concerning the safety of raw or undercooked food HACCP Plan (Hazard Analysis Critical Control Point Plan) – Written document delineating HACCP principles in use Variance – Written document issued by the Board of Health I,, the undersigned attest to the accuracy of the information in the application and I affirm that the food operation with comply with 105 CMR 590.000 and all other applicable laws. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. Pursuant to MGL Chapter 62C, § 49A, I certify under the penalties of perjury that to the best of my knowledge and belief have filed all State tax returns and paid all State taxes required under law. Federal Identification Number Signature of Individual or Corporate Officer Date Watertown Health Department Food Plan Review Application – Change in Menu, Equipment, or Operations Page 5 | 5 WATERTOWN HEALTH DEPARTMENT APPLICATION FOR A PERMIT TO OPERATE A FOOD ESTABLISHMENT REVIEWER’S COMMENTS Reviewer’s Comments: (Note why any item was “unacceptable.”) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _________________________________ __________________ Reviewer’s Signature Date _________________________________ Reviewer’s Title Approval: _________________________ Date____________________ Disapproval: _______________________ Date ___________________ Reason(s) for disapproval: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________