CITY OF HAVERHILL

4 Summer Street Room 210

Haverhill, MA 01830

(978)-374-2335

 

 BOARD OF HEALTH

 

APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT

Fee:$20.00 Please make check payable to: City of Haverhill

 

 

________________________________________________________________________________________________________

Name Of Establishment                                                                                                                          Contact Telephone #

________________________________________________________________________________________________________

Name of Event/Location                                                                                                                     Date of Scheduled Event

________________________________________________________________________________________________________

Operator Mailing Address

1. Before completing this application, read the temporary food establishment  “Are You Ready?” Checklist. Have you read these materials ____YES ____NO

2. MENU: Attach  or list below all items. Any Changes must be submitted  and approved by the Haverhill Board of Health at least 5 days prior  to the event.

3. Will all foods be prepared at the temporary food establishment booth?

____YES     Complete SECTION A below if you answered YES to question 3.

____NO      Attach a copy of the permit where the food will be prepared. If food is prepared at a  licensed            establishment in Haverhill list name only._________________________________________

                      Complete SECTION A and B below if you answered NO to question 3.

4. List each food item prepared, and for each item check  which preparation procedure will occur.

    Please attach a copy of the menu.                                

SECTION A:  At the Booth

Food	Thaw	Cut / Assemble	Cook	Cool	Cold Holding	Reheat	Hot Holding	Portion Packaging

 

SECTION B: At the licensed food establishment.

Food	Thaw	Cut / Assemble	Cook	Cool	Cold Holding	Reheat	Hot Holding	Portion Packaging

5.Food Source(s):_______________________________________________________________________

Source and Storage of water/ice:___________________________________________________________

Storage and disposal of wastewater:_________________________________________________________

I certify that I am familiar with 105 CMR 590.00 Minimum Sanitation Standards for Food Establishments-Article X, and the above described establishment will be operated and maintained in accordance with the regulations.

Applicant’s Signature:_____________________________________________________________________________Date:_______