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APPLICATION

APPLICATION FOR TEMPORARY FOOD PERMIT

Date:  _________________               FEE:  $75.00______________________ (non-refundable)

                                                                        (SUBJECT TO ADDITIONAL FEES AS NECESSARY)

                                                                            Make checks payable to the Town of Sunderland

Name of Event/Location ________________________________________________________

Date(s) of Event/Hours of Operation ________________________________________________

Name of Establishment __________________________________________________________

Name of Owner/Corp/President ____________________________ Title ___________________

Owner’s Address _______________________________________________________________

City, State, Zip ___________________________________________ Phone ________________

Mailing Address (if different) _____________________________________________________

1. Before completing this application, read Food Safety at Temporary Events and the Temporary Food Establishment “Are You Ready” checklist (both of these documents are attached).

Have you read this material?     Y          N

2. Menu – List all items you intend to serve.  Any changes must be submitted in writing and approved by the Board of Health at least 5 days prior to the event.

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

                        IF YES – complete section below     IF NO  - Fill out both A and B below

            SECTION A:  At the approved kitchen:

Include dates and times of food preparation and attach a copy of the BASE OF OPERATIONS food permit.

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

DATE/TIME        FOOD ITEM   THAW          CUT           COOK          COLD         REHEAT          HOT

                                                                                     ASSEMBLE                         HANDLING                       

SECTION B:  Food handling at booth includes:

                             FOOD ITEM    THAW          CUT           COOK          COLD         REHEAT          HOT

                                                                                     ASSEMBLE                         HANDLING                       

NOTE:  If additional space is needed, please use back of form.

5. Food source(s) list food supplies  __________________________________________

Source and storage of water/ice  ___________________________________________

Storage and disposal of wastewater  ________________________________________

Storage and disposal of trash  _____________________________________________

Means for Hand-washing  ________________________________________________

6. Draw a sketch of the booth below

I certify that I am familiar with 105 CMR 590.000 Minimum Sanitation Standards for Food Establishments – Article X and the 1999 Federal Food Code and the above-described establishment will be operated and maintained in accordance with regulations.

Pursuant to M.G.L. Chapter 62c, §49a, I certify, under then penalties of perjury that, I to the best of my knowledge and belief, have filed all state tax returns and paid all state taxes required under law.

MAKE CHECKS PAYABLE TO THE TOWN OF SUNDERLAND

Applicant’s Signature  _______________________________  Date __________________