AL AK AZ AR CA CO CT DE FL HI ID IL IA KS KY ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS DC FM GU MH MP PW PR VI

Sole Proprieter Partnership Corporation

AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Treasurer Name

Title

City

Emergency Contact Details

Phone #

Phone #

Email

Alternate Certified Food Protection Manager Details

Principal Officer

Email

Clerk

Full Name

Corporate Name

State

Certificate #

Date of Incorporation

Title

District/Regional Manager Details

Address

Expiration Date

City, State, ZIP

Certificate #

State

Phone #

State of Incorporation

First Name

Address

Address

Additional Owners Details

Applicant Details

Certified Food Protection Manager Details

Last Name

Expiration Date

SSN/Federal ID #

Corporation Details

ZIP

ZIP

Full Name

Phone #

President Name

Full Name

Date of Birth

Ownership Type

Last Name

Email

First Name

City

Phone #

City, State, ZIP

Address

Retail Food Food Service Both

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Establishment Type?

Location of hand wash/toilet facilities on route

Church/Non Profit

Tuesday

For Mobile Food Units

The operator does not prepare, but offers for sale, only pre-packaged food that does not require time/temperature control for safety.

Farmers Market

The operator prepares only food that does not require time/temperature control for safety.

If yes, # of seats

Temporary (Up to 14 Days)

The operator prepares food for service to a highly susceptible population

Monday

Phone #

The operator prepares, offers for sale, or serves food that requires time/temperature control for safety in advance in quantities based on projected consumer demand and discards food that is not sold or served at an approved frequency.

Catering

The operator prepares food that requires time/temperature control for safety in advance using a food preparation method that involves two or more steps which may include combining ingredients; cooking; cooling; reheating; hot or cold holding; freezing; or thawing.

Address

The operator prepares, offers for sale, or serves food that requires time/temperature control for safety using time as the public health control.

Friday

Are there one or more persons on duty at all times trained in anti-choking techniques?

Ice Cream Vendor

Mobile

Food Preparation Information

Thursday

The operator prepares food for delivery to and consumption at a location off the premises of the food establishment where it is prepared

Saturday

Residential Kitchen

If yes, state SqFt

Sunday

Food and Milk Establishment Details

Have you answered all the above questions?

Base of Operations Name

The operator prepares, offers for sale, or serves food that requires time/temperature control for safety, only to order upon a consumer’s request.

Days and Hours of Operation

License Plate #

Wednesday

Does the establishment have mobile food unit?

Yes No

Yes No

Yes No

General Retail 21+ Only

Yes No

Are you selling cigarettes?

Tobacco Product Sales Permit Details

Cigar and/or smoking tobacco?

Type of Sales

Electronic nicotine delivery systems?

Received regulation copy?

Yes No

Yes No

Yes No

Brands/Trade names for product sales

Received regulation copy?

Is the water supply public?

Is the plant constructed?

Massachusetts ice cream sales last year (In Gallons)

If yes, from whom?

Capacity of Freezers (In Gallons)

Location of Plants

# of Freezers

If no, mention the water source

Laboratory for monthly bacteria testing

Frozen Desserts Manufacturer Details

Is the mix purchased?

Food & Milk Establishment Permit

• Integrated Pest Management (IPM) plan.
• Food Safety Certifications.
• Plan for management of grease, fats, and oils.
• Allergen awareness training certificates.
• Name of vendor for trash removal and frequency of removal.
• Permit numbers for dumpsters (Permit from Peabody Fire Department required for dumpsters)
• For Establishments with a base of operations, provide a copy of the leasing agreement.
• Plan Review Documents.
1. Name and Title of Designer and Contractor (include contact information for each).
2. Total Square Feet of Food Establishment
3. Floor plan showing location of all equipment (include storage for maintenance tools -brooms, mops etc.)
4. Specifications for dry storage, including depths of shelves, total linear feet of shelving, storeroom floor area in sq.ft., clearance between shelves and floor, etc.
5. Summary of hot water supply requirements.
6. Summary of reach-in cooler and walk-in cooler space in gross cubic feet (cu ft).
7. Summary of reach-in freezer and walk-in freezer space in gross cubic feet (cu ft).
8. Material specifications for floors, ceilings and walls
9. Proposed menu

Frozen Desserts AND/OR Ice Cream Mix

• Provide state hawker’s license. (For Mobile Vendors)

Tobacco Product Sales Permit

• Massachusetts Department of Revenue Retailer License for Sale of Cigarettes (If applicable).
• Massachusetts Department of Revenue Retailer License for Sale of Cigars and Smoking Tobacco (If applicable).
• Massachusetts Department of Revenue Retailer License for Sale of Electronic Nicotine Delivery System (If Applicable).

Attachments

Late Fee Description	Fee
Tobacco Products Sales Permit	$50
Frozen Desserts Manufacturer License	$25
Food Service Establishment	$50
Retail Food Establishment	$50

Amount Due

Fee Description	Fee
Rodent Control Fee	$25
Tobacco Products Sales Permit	$100
Frozen Desserts Manufacturer License	$25
Food Service Establishment	$100 for 0-50 Seats $125 for 51-150 Seats $150 for 151-499 Seats $1 for each additional seat above 499
Retail Food Establishment	$50 for 0-1000 SqFt $100 for 1001-10000 SqFt $250 if more than 10000 SqFt

Fee Schedule

Pay Now Pay Later

Certification

Frozen Desserts AND/OR Ice Cream Mix

I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all laws of the Commonwealth of Massachusetts pertaining thereto and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions.

Food & Milk Establishment Permit

I hereby attest to the accuracy of the information provided in this application and I affirm that I will comply with the Federal Food Code and the State Sanitary Code and all other applicable codes. I will allow the Peabody Board of Health or its agent(s) access to this food establishment and to the records as allowed under said Codes.

Tobacco Product Sales Permit

I hereby agree to read and abide by the Regulation of the Peabody Board of Health Restricting the Sale of Tobacco Products and Massachusetts General Laws, Chapter 270, Section 6 & 7. The applicant agrees to instruct all sales staff on the Regulations and federal, state and local laws regarding sales of tobacco products.

I hereby state that I have read and understand the requirements of the Regulation of the Peabody Board of Health Restricting the Sale of Tobacco Products.

Applicant Signature

Preferred Payment Method