Temporary Food Permit

CITY OF HAVERHILL

4 Summer Street Room 210

Haverhill, MA 01830

(978)-374-2335

 

�BOARD OF HEALTH

 

APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT

Fee:$50.00 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:_______

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