HAVERHILL HEALTH DEPARTMENT
CITY HALL, ROOM 210
4 SUMMER ST
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE:_____________________
NAME OF ESTABLISHMENT_____________________________________________
BUSINESS ADDRESS____________________________________________________
TELEPHONE # _________________________________________________________
MAILING ADDRESS (IF DIFFERENT)_____________________________________
NAME & TITLE OF APPLICANT__________________________________________
ADDRESS OF APPLICANT____________________________/TEL #______________
NAME OF OWNER (IF DIFFERENT FROM APPLICANT)______________________
IF CORPORATION OR PARTNERSHIP, GIVE NAME, TITLE & HOME ADDRESS OF OFFICERS OR PARTNERS.
___________________________________________________________________________________
___________________________________________________________________________________
STATE OF
NAME & ADDRESS OF LOCAL AGENT_______________________________________________________________________
EMERGENCY RESPONSE PERSON’S
NAME, ADDRESS & TELEPHONE ______________________________________________________________________________
TYPE OF ESTABLISHMENT FEE AMOUNT TO BE PAID
PLEASE CHECK
RETAIL FOOD _________ $50.00 __________
FOOD SERVICE _________ $75.00 __________
CATERER _________ $50.00 __________
MOBILE FOOD _________ $35.00 __________
MILK _________ $10.00 __________
SUPERMARKET_________ $125.00 __________
TOTAL __________
PAYMENT IS DUE WITH APPLICATION
NUMBER OF SEATS_______________ NUMBER OF NON-SMOKING SEATS____________
IF 25 SEATS OR MORE, ARE EMPLOYEES TRAINED IN ANTI-CHOKING PROCEDURES?
(ATTACH CERTIFICATES)
NAME OF CERTIFIED FOOD HANDLER __________________________________________
(ATTACH CERTIFICATES)
ADDITIONAL INFORMATION:
APPLICANTS FOR
WATER SOURCE__________________________ SEWAGE_____________________________
DAYS & HOURS OF OPERATION__________________________________________________
RESTAURANT:
SIGNATURE OF APPLICANT_____________________________________________________
PURSUANT TO M.G.L. CHAPTER 62C, SECTION 49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, DO TO THE BEST OF MY KNOWLEDGE AND BELIEF, HAVE FURNISHED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER LAW.
SOCIAL SECURITY NUMBER OR SIGNATURE OF INDIVIDUAL OR
FEDERAL IDENTIFICATION NUMBER OR CORPORATE NAME
_________________________________ _____________________________________
BOARD OF HEALTH USE ONLY
___________________________________________________________________________________
DATE RECEIVED DATE INSPECTED APPROVED BY
__________________ _____________________ ______________________