Type of Food Operation - Newton, MA
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HEALTH AND HUMAN SERVICES DEPARTMENT 1000 Commonwealth Avenue Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063 TDD/TTY 617.796.1089 1 City of Newton Ruthanne Fuller Mayor FOOD ESTABLISHMENT PLAN REVIEW APPLICATION Complete the Following Application(s). Please Print Legibly. Incomplete applications and missing documents may cause a delay in the decision-making process. Date: Type of Food Operation ☐ Restaurant ☐ Retail Market ☐ Frozen Dessert Manufacturer - Retail & Wholesale Complete Attachment A: Frozen Dessert License Application ☐ Institution ☐ Daycare ☐ Other (Specify): ☐ New ☐ Remodel ☐ Conversion Name of Establishment: Establishment Address: Newton, MA Zip: 024 Establishment Phone: Number: 617- Name of Owner: Owner’s Mailing Address: Owner’s Phone Number: Email: Applicant’s Name: Email: Title: ☐ Owner ☐ Manager ☐ Contractor ☐ Architect ☐ Other: Applicant’s Mailing Address: Applicant’s Phone Number: HOURS OF OPERATION Sun Mon Tue Wed Thu Fri Sat Will the establishment apply for seating? ☐ Yes ☐ No • Please Note: According to MA General Law Chapter 140 Section 2, Food Establishments that offers seating to the Public for consumption on the premises requires a Common Victualler (CV) License. Additionally, According to MA General Law, Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking procedures at all times the establishment is open to the public.
Transcript of Type of Food Operation - Newton, MA
Plan Review, Food Establishment, Frozen Dessert Applications with
Guidelines and Workers Compensation FormNewton, MA 02459 Telephone
617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
Complete the Following Application(s). Please Print Legibly.
Incomplete applications and missing documents may cause a delay in the decision-making process.
Date: Type of Food Operation
Restaurant Retail Market Frozen Dessert Manufacturer - Retail & Wholesale Complete Attachment A: Frozen Dessert License Application
Institution Daycare Other (Specify):
New Remodel Conversion
Name of Establishment: Establishment Address: Newton, MA Zip: 024 Establishment Phone: Number: 617- Name of Owner: Owner’s Mailing Address: Owner’s Phone Number: Email: Applicant’s Name: Email: Title: Owner Manager Contractor Architect Other: Applicant’s Mailing Address: Applicant’s Phone Number:
HOURS OF OPERATION
Sun Mon Tue Wed Thu Fri Sat Will the establishment apply for seating? Yes No
• Please Note: According to MA General Law Chapter 140 Section 2, Food Establishments that offers seating to the Public for consumption on the premises requires a Common Victualler (CV) License. Additionally, According to MA General Law, Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking procedures at all times the establishment is open to the public.
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If known, number of Seats authorized by CV: NA (No seats) Will the establishment apply for an Alcohol License?
Yes No
FOOD ESTABLISHMENT
Area of Facility (ft²): Number of Floors: Maximum # of Meals to be served (approximate): Breakfast: Lunch: Dinner:
TYPE OF SERVICE(S)
Sit Down Meals Take Out Only Caterer Single-Use Utensils Multi-Use Utensils Will the establishment have entertainment (music, television etc.)? Yes No Will the establishment have Sunday entertainment? Yes No Will there be outdoor dining? Yes No
FOOD SUPPLY Food Sources (Company Name(s)):
• Foods to be sold at a retail operations shall be purchased from licensed wholesale operations
How often will refrigerated foods be delivered? How often will frozen foods be delivered? How often will dry goods be delivered?
Provide the amount of space (cubic feet) allocated for:
Refrigerator Storage: Freezer Storage: Dry Storage: Identify the location and containers that will be used to store bulk food products (rice, sugar etc.): List all foods that will be cooked and cooled: List all foods that will be cooked, cooled and reheated: List all foods that will be hot held prior to service:
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Ready to Eat Foods (RTE) (e.g. salads, cold sandwiches, and raw molluscan shellfish):
Produce:
Poultry:
Meat:
Hot holding for service of TCS (Time / Temperature Control for Safety Food) Foods Maintained at 135°F and above
Type of unit(s): Number of unit(s):
Location:
Cold holding for service of TCS Foods - Maintained at 41°F and below
Type of unit(s): Number of unit(s):
Location:
Will any of the following Special Processing Methods be used? Yes No • Reduced Oxygen Packaging (ROP), Use of Additives to Render a Food Non-TCS (Acidification), Curing and
Smoking for Preservation, Cook-Chill, Sous Vide, Live Molluscan Shellfish Tank, Sprouted Seeds, Fermenting
Some Special Processes require a HACCP(Hazard Analysis Critical Control Point) Plan and / or a Variance Please Note: There is an additional $50.00 Fee for the Review of Special Processes / Variance Requests
Will a HACCP Plan be submitted? Yes No • If yes, in addition to this application, complete the “Hazard Analysis Critical Point Plan Review Application”.
Will a request for a Variance be requested? Yes No
• If yes, complete the “Request for Variance Form” including the “Granted Variance” Section of the form Will the establishment partially cook Animal Foods? Yes No
• If yes, a plan must be submitted for review and approval Will the establishment use Time as a Public Health Control? Yes No • If yes, complete “Time as a Public Health Control (TPHC) Request” form
Explain the Handling / Preparation Procedures for the following categories of food. Describe the processes from receiving to service including:
1. How the food will arrive (frozen, fresh, packaged, etc.) 2. Where the food will be stored 3. Where the food will be washed, cut, marinated, breaded, cooked etc. (prep table, sink, counter etc.) 4. When food will be handled / prepared (time of day and frequency / day)
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Seafood:
Will the basement (if applicable) be used? Yes No What will the basement (if applicable) be used for: Food Preparation Storage Only Note: If the basement will be used for Food Preparation, the submitted plans shall include the layout and equipment specifications.
Explain how the basement will be used for food preparation: PEST CONTROL Will all outside doors be self-closing and rodent proof? Yes No Will screens be provided on all entrances left open to the outside? Yes No Will all openable windows have mesh screening (minimum #16 mesh)? Yes No Will air curtains be used? Yes No
• If yes, where will they be located? WATER SUPPLY What is the capacity and location of the water heater?
Will an ice machine be installed? Yes No • If yes, where?
WARE & DISHWASHING
Will the largest pot & pan fit into each compartment of the 3-compartment sink? Yes No If No, describe the cleaning method that will be used: Describe the location & type of device used for air drying clean equipment: Will a dish / glass machine be used? Yes No
• If yes, what will be the final rinse sanitizing cycle? Hot Water Chemical Will the dish / glass machine final rinse be under pressure?
Yes No • If yes, will the machine have a pressure gauge? Yes No
Will the machine be equipped to automatically dispense detergents and sanitizers? Yes No What type of device will be installed on the ware washing machine to verify that detergents and sanitizers are delivered or not delivered to the respective washing and sanitizing cycles? Visual Audible Please note: A ware washing machine shall be equipped to automatically dispense detergents and sanitizers and incorporate a visual means to verify that detergents and sanitizers are delivered or a visual or audible alarm to signal if the detergents and sanitizers are not delivered to the respective washing and sanitizing cycles. What type of sanitizer and the brand name will be used on food contact surfaces?
Chlorine: Quaternary:
Yes No
• If no, where will employees store personal items? Identify the storage location for poisonous or toxic materials (chemical storage):
Identify how grease will be disposed:
How often will the grease trap(s) be cleaned?
Identify the location of grease storage containers:
REFUSE Will refuse / garbage be stored inside? Yes No
• If yes, describe where: Identify how and where garbage cans and floor mats will be cleaned:
Will a dumpster be used? Yes No
• If yes, how many? Size: Frequency of pick-up: Name of company used for dumpster pick-up: Name of company used for grease pick-up:
Note: All Waste Disposal Companies (Offals) must be licensed with the City of Newton Health and Human Services Department Describe the surface and location where the dumpster / garbage will be stored outside:
Is there a Written Employee Health Policy for ALL Employees’? Yes No
• If yes, provide a copy of the Written Employee Health Policy • If no, the FDA “Employee Health and Personal Hygiene Handbook” can be used to develop a Written Policy
The Handbook can be obtained online
http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or
Projected Start Date: Projected Completion
Date: Projected Establishment Opening Date:
Please Note: After six (6) months if the work has not started or an extension has not been granted by the Newton
Health and Human Services Department, your plan review application will be considered null and void. Fees will not be refunded.
Fiberglass Reinforced Panels (FRP), Ceramic Tile etc.).
AREA
FLOOR
Completed Food Establishment Plan Review Application Form
All Applicable Fees. Cash is not accepted. Please make checks / money orders made payable to the “City of Newton”. All Fees are non-refundable.
A copy of the Written Employee Health Policy (if new establishment and / or new owner)
Proposed Menu or complete list of food and beverages to be offered (Including seasonal, off site and banquet / catering menus)
Plan(s) or Sketch of Food Establishment drawn to scale showing location of equipment, plumbing, electrical and mechanical services
Equipment schedule including location, plumbing, drain and electrical connections
Manufacturer Equipment Specification Sheets for each piece of equipment to be used in the Food Establishment
Previously “used” or refurbished equipment must be evaluated by a Certified Refrigeration Company / HVAC (Heating Ventilation and Air Conditioning) / Professional. This evaluation must be submitted
Site plan showing location of food establishment location of building on site including alleys, streets and location of any outside equipment or facilities (dumpsters, well, septic system if applicable)
Completed Application for Permit to Operate a Food Establishment (if new establishment and / or new owner)
Workers’ Compensation Insurance Affidavit
Certified Food Manager’s Certificate Allergy Awareness Certificate Choke Save Training Certificate
Completed Frozen Dessert Application (if applicable)
HACCP (Hazard Analysis Critical Control Plan) Plan Review Application (if applicable) containing all required information (for Special Processes requiring a HACCP Plan)
Request for Variance (if applicable) for Special Processes and Time as a Public Health Control
Please note that any missing information may cause a delay in the decision making process
STATEMENT: I, hereby certify that the above information is correct and I fully understand that any deviation from the above without prior permission from the Newton Health and Human Services Department may nullify final approval. Signature: Title:
Print Name: Date:
Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code, law or regulation that may be required – Federal, State or Local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with the Local and State Laws governing Food Service Establishments.
FOR OFFICIAL USE ONLY Date Submitted: Fee Received: $ Check #: Risk Category: 1 A / 1 B
$50.00 2
$50.00 3
$100.00 4A
$150.00 4B
The Food Codes can be found at the following websites: http://www.Newtonma.gov/health
State Sanitary Code Chapter X – Minimum Sanitation Standards for Food Establishments 105 CMR 590.000: http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code: http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
FDA 2013 Food Code Supplement: http://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm453530.htm Frozen Desserts and Frozen Dessert Mixes 105 CMR 561.000: www.mass.gov/eohhs/docs/dph/regs/105cmr561.rt
The Health and Human Services Department is open 8:30 A.M. - 5:00 P.M. M-F and until 8:00 P.M. on Tuesdays If there are questions please call the Health and Human Services Department at 617-796-1420
RISK CATEGORIZATION OF FOOD ESTABLISHMENTS
RISK CATEGORY DESCRIPTION FREQUENCY
1 (A & B)
Examples include most convenience store operations, hot dog carts, and coffee shops. Establishments that serve or sell only pre-packaged, non time/temperature control for safety (TCS) foods. Establishments that prepare only non-TCS foods. Establishments that heat only commercially processed, TCS foods for hot holding. No cooling of TCS foods. Establishments that would otherwise be grouped in Category 2 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors.
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Examples may include retail food store operations, schools not serving a highly susceptible population, and quick service operations. Limited menu. Most products are prepared/cooked and served immediately. May involve hot and cold holding of TCS foods after preparation or cooking. Complex preparation of TCS foods requiring cooking, cooling, and reheating for hot holding is limited to only a few TCS foods. Establishments that would otherwise be grouped in Category 3 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors. Newly permitted establishments that would otherwise be grouped in Category 1 until history of active managerial control of foodborne illness risk factors is achieved and documented.
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3
An example is a full service restaurant. Extensive menu and handling of raw ingredients. Complex preparation including cooking, cooling, and reheating for hot holding involves many TCS foods. Variety of processes require hot and cold holding of TCS food. Establishments that would otherwise be grouped in Category 4 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors. Newly permitted establishments that would otherwise be grouped in Category 2 until history of active managerial control of foodborne illness risk factors is achieved and documented.
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PLAN REVIEW APPLICATION GUIDELINES FOOD ESTABLISHMENT
The following items are required to be submitted for a complete plan review. Any missing information could cause a delay in the process. After six months if the work has not started or an extension has not been granted by the Newton Health and Human Services Department, your plan review application will be considered null and void. Fees will not be refunded.
1) Other than Establishments which sell only commercially packaged foods all other Food Establishments are
required to have a Person in Charge (PIC) who is a Certified Food Protection Manager. The PIC shall be a full-time employee at least 18 years of age. If the Certified Food Protection Manager is not present at the establishment, there must be a designated PIC who can demonstrate the same level of knowledge as required by the Certified Food Manager. Certified Food Manager class instructors can be found at the MA Food Protection Program website:
http://www.mass.gov/eohhs/docs/dph/environmental/foodsafety/food-safety-exam-trainers.pdf
In addition, the Certified Food Protection Manager must obtain a certificate showing that they viewed the Allergen Awareness Training video. The PIC will be responsible for training the employees on allergy awareness. The Certified Food Protection Manager and Allergy certificates shall be prominently posted in the establishment next to the food establishment permit and the Common Victualler license (if applicable). The video can be viewed on the MA Food Protection Program website: http://www.mass.gov/dph/fpp
Each food establishment having a seating capacity of 25 persons or more have on its premises, while food is being served, an employee trained in manual procedures to remove food lodged in a person’s throat. Proof of training for choke save must be available on site. All of these certificates must be obtained PRIOR to opening. Classes are offered in Newton and Framingham on a monthly basis. The class schedule can be obtain on the City of Newton’s website: http://www.newtonma.gov/gov/health/enviro/forms/food.asp A written Employee Health Policy must be submitted. The policy should consist of excluding and restricting employees on the basis of their health and activities as they relate to diseases that are transmissible through food. Written policy includes a statement regarding employee responsibility to notify management of symptoms and illness identified in the Food Code. The “FDA Employee Health and Personal Hygiene Handbook” contains forms and is a great resource that can be used. The handbook can be found at: http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or on the City of Newton’s website: http://www.newtonma.gov/gov/health/enviro/forms/food.asp
2) Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn
to a minimum scale of ¼ inch = 1 foot. Plans shall include:
• Proposed menu: List any food that will be prepared overnight, special processes, projected daily meal volume for food service operations, seating capacity and food sources.
• Food equipment schedule to include make and model numbers and listing of equipment that is certified or
classified for sanitation by an ANSI accredited certification program.
• All new or replaced equipment must be capable of cooling and holding internal food temperatures at 41ºF and below.
• All existing refrigeration equipment must be evaluated by a HVAC (Heating, Ventilation, Air
Conditioning) Specialist certifying that the equipment is capable of cooling and holding internal food temperatures at 41ºF and below. Any existing dish / glass machine must also be evaluated by an industry certified technician. Reports should be submitted as part of the Plan Review.
3) Show the location and when requested, elevated drawings of all food equipment.
• Each piece of equipment must be clearly labeled on the plan with its common name.
• Submit drawings of self-service hot and cold holding units with sneeze (breath) guards.
• Designate clearly on the plan equipment for rapid cooling, including ice baths, refrigeration and hot holding.
• Label all sinks and the designated use i.e. hand washing, utensils cleaning, food prep etc. 4) Provide on the Floor Plan: Room size, aisle space, space between and behind equipment and the placement of
the equipment. 5) Show all auxiliary areas such as storage rooms, garbage rooms, toilets, basements used for storage or food
preparation. Include and provide specifications for: Entrances, exits, loading / unloading areas and docks.
• Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases.
• Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead wastewater lines, hot water generating equipment with capacity and recovery rate, backflow prevention and wastewater line connections.
• Lighting schedule with a shield, coating, or otherwise shatter-resistant :
At least 540 lux (50 foot candle) at food prep areas where employees work with sharp or mechanical equipment.
220 lux (20 foot candle) at food service / preparation areas. 110 lux (10 foot candle) in storage areas.
• Source of water supply and method of sewage disposal.
6) A color-coded flow chart demonstrating flow patterns for:
• Food : Receiving, Storage, Preparation, Service
• Food and Dishes: Portioning, Transport, Service
• Dishes: Clean, Soiled, Cleaning, Storage
• Utensils: Storage, Use, Cleaning
• Trash and Garbage: Service Area, Holding, Storage 7) Ventilation schedule for each room. 8) Placement for mop sink / curbed cleaning facility with designated area for hanging wet mops. 9) Cabinets / Areas for storing toxic chemicals. 10) Dressing rooms, locker areas, employee rest area, coat rack. 11) Site plan for new construction.
Updated 4/9/18
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION FOR LICENSE TO MANUFACTURE FROZEN DESSERTS AND / OR
ICE CREAM MIX In accordance with the provisions of Massachusetts General Law Chapter 94, Section 65H and 105 CMR 561.000 Frozen Desserts and Frozen Dessert Mixes, the undersigned hereby applies for a license for the wholesale / retail manufacture of frozen desserts and or ice cream mix.
Please Print Legibly
Establishment Phone Number: New Establishment Existing Establishment Same as above
If not the same as above, list the location of each establishment (plant) where product(s) will be manufacture:
Applicant’s Name:
Applicant’s Address:
Owner’s Name:
Type of Business Retail Manufacturer Wholesale Manufacturer
If Wholesale Manufacturer, brand and trade name(s) of products:
Type of Product
Frozen Yogurt (not soft serve)
Frozen Yogurt (not soft-serve)
Sorbet (only if dairy-based) Other:
If Frozen Yogurt is manufactured, will it contain “friendly” cultured bacteria (live cultures)? Yes No
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Described the following Source(s) of Ingredients:
No milk or cream from a source outside of the United States, subject to the Federal Import Milk Act, 21 U.S.C §141 et seq., shall be used unless the importer has documentation to show that the exporter is in compliance with 21 CFR Part 1210.
Will a Soft-Serve Machine(s) be used? Yes – Type of Machine: No
How many machines?
Submit the specification sheets for the machine(s)
If No, describe how the product will be prepared and the storage of the final product:
Will commercially pasteurized product(s) be used? Yes No
If No, describe what will be used and how:
Will the above final product be pasteurized? Yes No
If Yes, describe the pasteurization process:
How will the refrigerated and frozen product be delivered and transported?
If transported, how will the product temperature be monitored?
How often will the surfaces and equipment be cleaned and sanitized?
What are the procedures for cleaning the equipment and surfaces and what product will be used?
How will the equipment and surfaces be sanitized?
Name and Type of Sanitizer:
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All manufactured frozen desserts produced shall have the following tests performed by a certified laboratory on its finished product monthly.
Bacterial and other Standards shall not exceed the following standards Item Standard Plate Count (SPC) Coliform
Finished Products Produced by means other than a Soft-Serve Machine
50,000/g
20/g
50,000/g
50/g
** If Frozen Yogurt contains “live cultures”, SPC laboratory testing is not required **
Copies of all test results for required tests shall be submitted directly to the Newton Health and Human Services by the certified laboratory within three (3) business days of the completion of the tests.
SUBMIT THE FOLLOWING
Completed Application for License to Manufacture Frozen Desserts and / or Ice Cream Mix
Completed Food Establishment Plan Review and Food Establishment Application (for new food establishments only) including all of the required documents. Page 6 on the Plan Review Application contains the required documents. License fee of $5.00
Note: This can be included in the total fee for the Plan Review and Food Establishment Permit Equipment Specification sheets used in the process (i.e. Soft-Serve Machine(s) etc.) For existing food establishments, provide a sketch of the processing area and / or the placement of the Soft-Serve Machine(s)
ALL APPLICATIONS MUST BE FILLED OUT COMPLETELY WITH A FEE PAYABLE TO THE “CITY OF NEWTON”
CASH AND CREDIT CARDS ARE NOT ACCEPTED AT THIS TIME ALL FEES ARE NON-REFUNDABLE
Please note that any missing information may cause a delay in the decision making process.
STATEMENT: I,
hereby certify that the above information is
correct and I fully understand that any deviation from the above without prior permission from the Newton Health and Human Services Department may nullify final approval. Additionally, I certify I will manufacture such products only from pure and wholesome ingredients and only under sanitary conditions.
Signature:
Title:
• What types of establishments are considered frozen dessert manufacturers?
1.Wholesale manufacturing plants that pasteurize raw milk and cream; 2.Wholesale manufacturers who purchase a pasteurized mix and manufacture ice cream; 3.Retail manufacturers* who purchase a pasteurized mix and manufacture ice cream, soft-serve ice cream or frozen yogurt in a “frozen dessert freezing / dispensing machine.” *It is important that the term manufacturer be understood as it pertains to frozen desserts. The term manufacturer or frozen dessert manufacturer as it appears in the regulations includes any retail establishment operating a frozen dessert freezing/dispensing machine. A “frozen dessert freezing/dispensing machine” is any machine that freezes, mixes and dispenses frozen desserts. This includes soft serve machines frequently operated at the retail level. This means that all frozen dessert manufacturers, whether wholesale or retail, require licensing by the local board of health having jurisdiction.
• What types of establishments are NOT considered frozen dessert manufacturers? 1.Stores and restaurants that purchase ice cream in bulk and scoop it, but do not make ice cream in a frozen dessert freezing/dispensing machine; 2.Retail stores that purchase ice cream or other frozen desserts in pre-packaged retail containers for re-sale to the public; 3.Vending machines that dispense packaged ice cream, novelties, etc.; and 4.“Dispensing only machines.” Dispensing only machines are machines that dispense a prepackaged ready-to-use frozen dessert. These machines do not mix or freeze a mixture. They merely dispense it. Therefore the machine is not considered a manufacturing machine.
Testing and Testing Exemptions
105 CMR 561.007 states that all manufacturers must have their frozen dessert products tested monthly by an approved laboratory. Section 561.007(F) (2) (a) refers to seven categories of frozen dessert products. The intent is to require bacteriological testing for dairy-based frozen desserts only. Dairy-based frozen desserts such as ice cream, sherbet and frozen yogurt are frozen dessert products that contain dairy ingredients. Non-dairy frozen desserts no longer require bacteriological testing. Non-dairy frozen desserts, such as sorbet, water ices, Italian ice, slush and some frozen coffee beverages are frozen desserts that do not contain any dairy ingredients. These products do not pose the same potential for supporting pathogenic organisms as do frozen desserts that do contain dairy ingredients. Therefore, testing of non-dairy frozen desserts is no longer required. According to 105 CMR 561.007 all frozen dessert manufacturers (this includes soft serve dispensing machines and ice cream barrel freezers) shall have bacteriological tests performed on at least one dairy-based frozen dessert product per month by a certified laboratory. The laboratory must submit copies of the results to the board of health upon completion of the analysis. If the SPC is above the 50.000 limit, the Person-in-Charge (PIC) shall: 1. Review the cleaning and sanitization procedures for the machine. Check the machine’s specification sheets for additional instructions and cleaning protocols for the machine. 2. Evaluate the handling of the products / ingredients. 3. If SPC is above the limit for two (2) consecutive samplings, additional sampling will be required. If the Coliform Count is above the 20/g (produced other than from a soft-serve machine) or 50/g (products from a soft-serve machine), the PIC shall: 1.Review the cleaning and sanitization procedures for the machine. Check the machine’s specification sheets for additional instructions and cleaning protocols for the machine. 2. Evaluate the handling of the products / ingredients. 3. If one (1) sample is above the required standard, resampling will be required. The presence of coliform is an indicator of inadequate operational sanitation and controls somewhere in the process. Bacteria counts slightly above the standards should be a wake -up call. It should alert the machine operator that something might not be right with cleaning, temperature, storage or handling. If a high coliform count is found (coliform count is an indicator that pathogens might be present), further testing is necessary to confirm actual pathogens.
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Helpful Recommendations
• Check all pieces of the machines components for pitting, cuts, clean ability etc. Often worn parts can lead to bacteria problems even when cleaning and sanitizing are completed properly.
• Be sure to follow the disassembling, cleaning, sanitizing and assembly of the frozen dessert machines are performed as indicated by manufacturers’ recommendation and at the required frequency. Verify the machine has been maintained properly.
• Wear gloves when assembling the machine. Be sure to wash hands properly prior to glove use. .
Codes can be found at the following websites:
City of Newton http://www.newtonma.gov/health
MA State Sanitary Code Chapter X -
Minimum Sanitation Standards for Food Establishments 105 CMR 590.000 https://www.mass.gov/files/documents/2018/10/09/105cmr590.pdf
FDA 2013 Food Code
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION PERMIT TO OPERATE A FOOD ESTABLISHMENT
Complete the application below legibly. Enclose a fee payable to the “City of Newton” Cash is not accepted. Fees are non-refundable. Incomplete application may delay the permitting process.
Date: Type of Food Establishment: Mobile Stationary Temporary Permanent
Check One Check One
Will containers of Milk be sold? Yes No
If Yes, include a $10 Milk License Fee
Will Frozen Dessert(s) be Manufactured? Yes No
If Yes, complete a Frozen Dessert License Application
Will Catering be offered? Yes No
Catering is defined as Delivering AND Serving
Will there be seating? Yes No Number of Seats approved by Common Victualler (CV) License: Applicant’s Name: Title:
• To Quality for a Food Establishment Permit, an Applicant shall be an Owner or an Officer of the Legal Ownership
Mailing Address:
The Food Establishment is Legally Owned by (check one):
Association Corporation Individual Partnership Other :
Name of Legal Food Establishment Owner (as per the CV License application if applicable):
Owner’s Home Address:
Name of Contact Person (if Association, Corporation or Partnership):
Phone #: Email: • If Corporation, Association or Partnership, please attach a list of the Officer’s Names, Address and Phone Numbers
A. Name of Person Directly Responsible for the Food Establishment:
Title:
Address:
Phone #: Email:
B. Name of Person who functions as the Immediate Supervisor of the Person listed in A above:
Title: Zone Supervisor District Supervisor Regional Supervisor Other : Address:
Phone #: Email: Name of Emergency Contact Person: 24 Hour Phone #:
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Statement: I, affirm to comply with the MA Department of Public Health State Sanitary Code Chapter X – Minimum Sanitation Standards for Food Establishments (105 CMR590.000), the FDA Food Code and allow the regulatory authority access to the establishment as specified under § 8-402.11 and to the records specified under § 3-203.12, 5-205.13, 8-201.14(D)(6) and other information required by the regulatory authority. I understand that any deviation from the submitted and approved plan without prior approval from the Newton Health and Human Services Department may cause a delay in the permit process. Pursuit to M.G.L Chapter 62C, Section 49A, I hereby certify under the pains and penalties of perjury that, to my best knowledge and belief, the information provided above is true and correct and that I have filed all state tax returns and paid all state taxes required under law.
Federal Identification Number:
Food Establishment Fee: (based on Risk Category assigned) $
Milk License (only if cartons of milk are sold): $
Frozen Dessert Manufacturing
Total Amount Enclosed: $
To obtain a permit to operate a Food Establishment please submit the following:
Completed “Application for a Permit to Operate a Food Establishment”. Please print legibly. Any missing information may cause a delay in the permit process. Do not leave any blank spaces.
According to MA General Law Chapter 140 Section 2, Food Establishments that offer seating to the public for consumption on the premises requires a Common Victualler (CV) License.
Permit Fee (determined by the Newton Health and Human Services Department) made payable to the “City of Newton”. Cash is not accepted. All fees are non-refundable.
Completed “Workers’ Compensation Insurance Affidavit”. Attached a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
A copy of your Written Employee Health Policy (if New Owner or New Food Establishment).
A copy of the Person-in-Charge (PIC) Certified Food Protection Manger AND Allergy Awareness Certificates (if New Owner or Food Establishment).
Copy of Choke Save card or certificate. Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking Procedures at all times the establishment is open to the public (if New Owner or Food Establishment).
Note: The Newton Health and Human Services (HHS) Department must be notified PRIOR to the following:
• Remodeling / Changing Equipment.
• Adding Special Processes such as but not limited to: Smoking of Foods / Acidification as means of Food Preservation, Reduced Oxygen Packaging (ROP), Partial Cooking of Raw Animal Foods, and Using Time as a Public Health Control. Detail plans and specific information must be submitted for review.
Written approval must be granted by the Department prior to implementing such processes.
Food Establishment Fee Schedule The Risk Category for the Food Establishment is assigned by the HHS Department
Milk License (selling containers of Milk): $10.00 Special Process Plan Review: $50.00 Risk Category 1A (only Commercially Packaged Foods, Convenience Stores): $50.00 Risk Category 1B (Coffee Shops, Residential Kitchens, Limited Operations) $150.00 Risk Category 2: $250.00 Risk Category 3: $300.00 Risk Category 4A (Highly Susceptible Populations (HSP) such as Preschools, Hospitals, Nursing Homes; Food Establishments with Special Processes): $300.00
Risk Category 4B (Supermarkets): $400.00 The Health and Human Services Department is open M – F from 8:30 A.M. - 5:00 P.M. and until 8:00 P.M. on Tuesdays.
If there are questions, please call the Health and Human Services Department at 617-796-1420
18
The Food Codes can be found at the following websites:
105 CMR 590.000 http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
Office of Investigations Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly
Business/Organization Name:_________________________________________ __________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an organization should check box #1.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information.
Insurance Company Name:______________________________________________________________________________ Insurer’s Address:_____________________________________________________________________________________ City/State/Zip: ________________________________________________________________________________________ Policy # or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (check one): Building Department 3. City/Town Clerk 4.1. Licensing Board Board of Health 2.
5. Selectmen’s Office 6. Other _______________________________ Contact Person:_________________________________________ Phone #:_________________________________
1. I am a employer with _________ employees (full and/ or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers’ comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required]** 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers’ comp. insurance req.]
Are you an employer? Check the appropriate box: Business Type (required): 5. Retail
6. Restaurant/Bar/Eating Establishment
8. Non-profit
9. Entertainment
10. Manufacturing
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.
The Department’s address, telephone and fax number: The Commonwealth of Massachusetts
Department of Industrial Accidents Office of Investigations
Lafayette City Center 2 Avenue de Lafayette,
Boston, MA 02111-1750
Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 www.mass.gov/dia Form Revised 7/2019
Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees. Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire, express or implied, oral or written.” An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.” MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.” Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.”
Applicants Please fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company’s name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line.
Applicants
Slide Number 1
Slide Number 2
Slide Number 1
Slide Number 2
Institution: Off
Daycare: Off
New: Off
Remodel: Off
Conversion: Off
NA No seats: Off
Area of Facility ft²:
Number of Floors:
Breakfast:
Lunch:
Dinner:
Refrigerator Storage:
Freezer Storage:
Dry Storage:
Identify the location and containers that will be used to store bulk food products rice sugar etc:
List all foods that will be cooked and cooled:
1:
2:
3:
List all foods that will be cooked cooled and reheated:
1_2:
2_2:
3_2:
List all foods that will be hot held prior to service:
1_3:
2_3:
3_3:
undefined_6:
undefined_7:
Location:
undefined_8:
undefined_9:
Location_2:
Reduced Oxygen Packaging ROP Use of Additives to Render a Food NonTCS Acidification Curing and: Off
If yes in addition to this application complete the Hazard Analysis Critical Point Plan Review Application: Off
If yes complete the Request for Variance Form including the Granted Variance Section of the form: Off
undefined_10: Off
undefined_11: Off
Ready to Eat Foods RTE eg salads cold sandwiches and raw molluscan shellfish:
Produce:
Poultry:
Meat:
Seafood:
Yes_11: Off
Explain how the basement will be used for food preparation:
1_4:
2_4:
What is the capacity and location of the water heater:
Will an ice machine be installed: Off
If yes where:
Will the largest pot pan fit into each compartment of the 3compartment sink: Off
If No describe the cleaning method that will be used:
1_5:
2_5:
Describe the location type of device used for air drying clean equipment:
1_6:
2_6:
Will the machine be equipped to automatically dispense detergents and sanitizers: Off
undefined_14: Off
Visual: Off
Audible: Off
What type of sanitizer and the brand name will be used on food contact surfaces:
Chlorine: Off
Quaternary: Off
If no where will employees store personal items:
Identify the storage location for poisonous or toxic materials chemical storage:
Identify how grease will be disposed:
How often will the grease traps be cleaned:
Identify the location of grease storage containers:
REFUSE:
If yes describe where:
Identify how and where garbage cans and floor mats will be cleaned:
undefined_18: Off
Name of company used for dumpster pickup:
Describe the surface and location where the dumpster garbage will be stored outside:
Is there a Written Employee Health Policy for ALL Employees:
undefined_19: Off
WALLSGarbage Refuse Storage:
CEILINGGarbage Refuse Storage:
FLOORMop Service Sink:
WALLSMop Service Sink:
CEILINGMop Service Sink:
FLOORWare washing Area:
WALLSWare washing Area:
CEILINGWare washing Area:
FLOORWalkin Refrigerators Freezers:
WALLSWalkin Refrigerators Freezers:
CEILINGWalkin Refrigerators Freezers:
undefined_22: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow2:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow3:
undefined_23: Off
undefined_24: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow7:
undefined_25: Off
undefined_26: Off
undefined_27: Off
A copy of Certified Food Managers Certificate Allergy Awareness Certificate Choke Save Training Certificate:
Certified Food Managers Certificate: Off
Allergy Awareness Certificate: Off
undefined_28: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow14:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow15:
undefined_29: Off
STATEMENT I:
Print Name:
Date Submitted:
Fee Received:
2_7: Off
3_4: Off
4A: Off
4B: Off
1_7:
2_8:
Custard:
undefined_34: Off
undefined_40:
Other_2:
If Frozen Yogurt is manufactured will it contain friendly cultured bacteria live cultures Yes:
undefined_41: Off
Sources of Ingredients 1:
Sources of Ingredients 2:
Sources of Ingredients 3:
be used unless the importer has documentation to show that the exporter is in compliance with 21 CFR Part 1210:
Yes Type of Machine: Off
No_27: Off
1_8:
2_9:
If No describe what will be used and how:
1_9:
2_10:
1_10:
2_11:
undefined_44:
How will the refrigerated and frozen product be delivered and transported 1:
How will the refrigerated and frozen product be delivered and transported 2:
undefined_45:
If transported how will the product temperature be monitored 1:
If transported how will the product temperature be monitored 2:
undefined_46:
How often will the surfaces and equipment be cleaned and sanitized:
undefined_47:
What are the procedures for cleaning the equipment and surfaces and what product will be used 1:
What are the procedures for cleaning the equipment and surfaces and what product will be used 2:
undefined_48:
Name and Type of Sanitizer:
Completed Application for License to Manufacture Frozen Desserts and or Ice Cream Mix: Off
Completed Food Establishment Plan Review and Food Establishment Application for new food establishments only: Off
License fee of 500: Off
Equipment Specification sheets used in the process ie SoftServe Machines etc: Off
For existing food establishments provide a sketch of the processing area and or the placement of the: Off
STATEMENT I_2:
Catering is defined as Delivering AND Serving: Off
Will there be seating Yes: Off
No_33: Off
Applicants Name_3:
To Quality for a Food Establishment Permit an Applicant shall be an Owner or an Officer of the Legal Ownership:
Phone Number_2:
Name of Emergency Contact Person:
affirm to comply with the MA Department of Public Health State Sanitary Code:
Federal Identification Number:
undefined_55:
undefined_56:
Special Process Plan Review:
Risk Category 2:
Risk Category 3:
TDD/TTY 617.796.1089
Complete the Following Application(s). Please Print Legibly.
Incomplete applications and missing documents may cause a delay in the decision-making process.
Date: Type of Food Operation
Restaurant Retail Market Frozen Dessert Manufacturer - Retail & Wholesale Complete Attachment A: Frozen Dessert License Application
Institution Daycare Other (Specify):
New Remodel Conversion
Name of Establishment: Establishment Address: Newton, MA Zip: 024 Establishment Phone: Number: 617- Name of Owner: Owner’s Mailing Address: Owner’s Phone Number: Email: Applicant’s Name: Email: Title: Owner Manager Contractor Architect Other: Applicant’s Mailing Address: Applicant’s Phone Number:
HOURS OF OPERATION
Sun Mon Tue Wed Thu Fri Sat Will the establishment apply for seating? Yes No
• Please Note: According to MA General Law Chapter 140 Section 2, Food Establishments that offers seating to the Public for consumption on the premises requires a Common Victualler (CV) License. Additionally, According to MA General Law, Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking procedures at all times the establishment is open to the public.
2
If known, number of Seats authorized by CV: NA (No seats) Will the establishment apply for an Alcohol License?
Yes No
FOOD ESTABLISHMENT
Area of Facility (ft²): Number of Floors: Maximum # of Meals to be served (approximate): Breakfast: Lunch: Dinner:
TYPE OF SERVICE(S)
Sit Down Meals Take Out Only Caterer Single-Use Utensils Multi-Use Utensils Will the establishment have entertainment (music, television etc.)? Yes No Will the establishment have Sunday entertainment? Yes No Will there be outdoor dining? Yes No
FOOD SUPPLY Food Sources (Company Name(s)):
• Foods to be sold at a retail operations shall be purchased from licensed wholesale operations
How often will refrigerated foods be delivered? How often will frozen foods be delivered? How often will dry goods be delivered?
Provide the amount of space (cubic feet) allocated for:
Refrigerator Storage: Freezer Storage: Dry Storage: Identify the location and containers that will be used to store bulk food products (rice, sugar etc.): List all foods that will be cooked and cooled: List all foods that will be cooked, cooled and reheated: List all foods that will be hot held prior to service:
3
Ready to Eat Foods (RTE) (e.g. salads, cold sandwiches, and raw molluscan shellfish):
Produce:
Poultry:
Meat:
Hot holding for service of TCS (Time / Temperature Control for Safety Food) Foods Maintained at 135°F and above
Type of unit(s): Number of unit(s):
Location:
Cold holding for service of TCS Foods - Maintained at 41°F and below
Type of unit(s): Number of unit(s):
Location:
Will any of the following Special Processing Methods be used? Yes No • Reduced Oxygen Packaging (ROP), Use of Additives to Render a Food Non-TCS (Acidification), Curing and
Smoking for Preservation, Cook-Chill, Sous Vide, Live Molluscan Shellfish Tank, Sprouted Seeds, Fermenting
Some Special Processes require a HACCP(Hazard Analysis Critical Control Point) Plan and / or a Variance Please Note: There is an additional $50.00 Fee for the Review of Special Processes / Variance Requests
Will a HACCP Plan be submitted? Yes No • If yes, in addition to this application, complete the “Hazard Analysis Critical Point Plan Review Application”.
Will a request for a Variance be requested? Yes No
• If yes, complete the “Request for Variance Form” including the “Granted Variance” Section of the form Will the establishment partially cook Animal Foods? Yes No
• If yes, a plan must be submitted for review and approval Will the establishment use Time as a Public Health Control? Yes No • If yes, complete “Time as a Public Health Control (TPHC) Request” form
Explain the Handling / Preparation Procedures for the following categories of food. Describe the processes from receiving to service including:
1. How the food will arrive (frozen, fresh, packaged, etc.) 2. Where the food will be stored 3. Where the food will be washed, cut, marinated, breaded, cooked etc. (prep table, sink, counter etc.) 4. When food will be handled / prepared (time of day and frequency / day)
4
Seafood:
Will the basement (if applicable) be used? Yes No What will the basement (if applicable) be used for: Food Preparation Storage Only Note: If the basement will be used for Food Preparation, the submitted plans shall include the layout and equipment specifications.
Explain how the basement will be used for food preparation: PEST CONTROL Will all outside doors be self-closing and rodent proof? Yes No Will screens be provided on all entrances left open to the outside? Yes No Will all openable windows have mesh screening (minimum #16 mesh)? Yes No Will air curtains be used? Yes No
• If yes, where will they be located? WATER SUPPLY What is the capacity and location of the water heater?
Will an ice machine be installed? Yes No • If yes, where?
WARE & DISHWASHING
Will the largest pot & pan fit into each compartment of the 3-compartment sink? Yes No If No, describe the cleaning method that will be used: Describe the location & type of device used for air drying clean equipment: Will a dish / glass machine be used? Yes No
• If yes, what will be the final rinse sanitizing cycle? Hot Water Chemical Will the dish / glass machine final rinse be under pressure?
Yes No • If yes, will the machine have a pressure gauge? Yes No
Will the machine be equipped to automatically dispense detergents and sanitizers? Yes No What type of device will be installed on the ware washing machine to verify that detergents and sanitizers are delivered or not delivered to the respective washing and sanitizing cycles? Visual Audible Please note: A ware washing machine shall be equipped to automatically dispense detergents and sanitizers and incorporate a visual means to verify that detergents and sanitizers are delivered or a visual or audible alarm to signal if the detergents and sanitizers are not delivered to the respective washing and sanitizing cycles. What type of sanitizer and the brand name will be used on food contact surfaces?
Chlorine: Quaternary:
Yes No
• If no, where will employees store personal items? Identify the storage location for poisonous or toxic materials (chemical storage):
Identify how grease will be disposed:
How often will the grease trap(s) be cleaned?
Identify the location of grease storage containers:
REFUSE Will refuse / garbage be stored inside? Yes No
• If yes, describe where: Identify how and where garbage cans and floor mats will be cleaned:
Will a dumpster be used? Yes No
• If yes, how many? Size: Frequency of pick-up: Name of company used for dumpster pick-up: Name of company used for grease pick-up:
Note: All Waste Disposal Companies (Offals) must be licensed with the City of Newton Health and Human Services Department Describe the surface and location where the dumpster / garbage will be stored outside:
Is there a Written Employee Health Policy for ALL Employees’? Yes No
• If yes, provide a copy of the Written Employee Health Policy • If no, the FDA “Employee Health and Personal Hygiene Handbook” can be used to develop a Written Policy
The Handbook can be obtained online
http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or
Projected Start Date: Projected Completion
Date: Projected Establishment Opening Date:
Please Note: After six (6) months if the work has not started or an extension has not been granted by the Newton
Health and Human Services Department, your plan review application will be considered null and void. Fees will not be refunded.
Fiberglass Reinforced Panels (FRP), Ceramic Tile etc.).
AREA
FLOOR
Completed Food Establishment Plan Review Application Form
All Applicable Fees. Cash is not accepted. Please make checks / money orders made payable to the “City of Newton”. All Fees are non-refundable.
A copy of the Written Employee Health Policy (if new establishment and / or new owner)
Proposed Menu or complete list of food and beverages to be offered (Including seasonal, off site and banquet / catering menus)
Plan(s) or Sketch of Food Establishment drawn to scale showing location of equipment, plumbing, electrical and mechanical services
Equipment schedule including location, plumbing, drain and electrical connections
Manufacturer Equipment Specification Sheets for each piece of equipment to be used in the Food Establishment
Previously “used” or refurbished equipment must be evaluated by a Certified Refrigeration Company / HVAC (Heating Ventilation and Air Conditioning) / Professional. This evaluation must be submitted
Site plan showing location of food establishment location of building on site including alleys, streets and location of any outside equipment or facilities (dumpsters, well, septic system if applicable)
Completed Application for Permit to Operate a Food Establishment (if new establishment and / or new owner)
Workers’ Compensation Insurance Affidavit
Certified Food Manager’s Certificate Allergy Awareness Certificate Choke Save Training Certificate
Completed Frozen Dessert Application (if applicable)
HACCP (Hazard Analysis Critical Control Plan) Plan Review Application (if applicable) containing all required information (for Special Processes requiring a HACCP Plan)
Request for Variance (if applicable) for Special Processes and Time as a Public Health Control
Please note that any missing information may cause a delay in the decision making process
STATEMENT: I, hereby certify that the above information is correct and I fully understand that any deviation from the above without prior permission from the Newton Health and Human Services Department may nullify final approval. Signature: Title:
Print Name: Date:
Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code, law or regulation that may be required – Federal, State or Local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with the Local and State Laws governing Food Service Establishments.
FOR OFFICIAL USE ONLY Date Submitted: Fee Received: $ Check #: Risk Category: 1 A / 1 B
$50.00 2
$50.00 3
$100.00 4A
$150.00 4B
The Food Codes can be found at the following websites: http://www.Newtonma.gov/health
State Sanitary Code Chapter X – Minimum Sanitation Standards for Food Establishments 105 CMR 590.000: http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code: http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
FDA 2013 Food Code Supplement: http://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm453530.htm Frozen Desserts and Frozen Dessert Mixes 105 CMR 561.000: www.mass.gov/eohhs/docs/dph/regs/105cmr561.rt
The Health and Human Services Department is open 8:30 A.M. - 5:00 P.M. M-F and until 8:00 P.M. on Tuesdays If there are questions please call the Health and Human Services Department at 617-796-1420
RISK CATEGORIZATION OF FOOD ESTABLISHMENTS
RISK CATEGORY DESCRIPTION FREQUENCY
1 (A & B)
Examples include most convenience store operations, hot dog carts, and coffee shops. Establishments that serve or sell only pre-packaged, non time/temperature control for safety (TCS) foods. Establishments that prepare only non-TCS foods. Establishments that heat only commercially processed, TCS foods for hot holding. No cooling of TCS foods. Establishments that would otherwise be grouped in Category 2 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors.
1
2
Examples may include retail food store operations, schools not serving a highly susceptible population, and quick service operations. Limited menu. Most products are prepared/cooked and served immediately. May involve hot and cold holding of TCS foods after preparation or cooking. Complex preparation of TCS foods requiring cooking, cooling, and reheating for hot holding is limited to only a few TCS foods. Establishments that would otherwise be grouped in Category 3 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors. Newly permitted establishments that would otherwise be grouped in Category 1 until history of active managerial control of foodborne illness risk factors is achieved and documented.
2
3
An example is a full service restaurant. Extensive menu and handling of raw ingredients. Complex preparation including cooking, cooling, and reheating for hot holding involves many TCS foods. Variety of processes require hot and cold holding of TCS food. Establishments that would otherwise be grouped in Category 4 but have shown through historical documentation to have achieved active managerial control of foodborne illness risk factors. Newly permitted establishments that would otherwise be grouped in Category 2 until history of active managerial control of foodborne illness risk factors is achieved and documented.
3
PLAN REVIEW APPLICATION GUIDELINES FOOD ESTABLISHMENT
The following items are required to be submitted for a complete plan review. Any missing information could cause a delay in the process. After six months if the work has not started or an extension has not been granted by the Newton Health and Human Services Department, your plan review application will be considered null and void. Fees will not be refunded.
1) Other than Establishments which sell only commercially packaged foods all other Food Establishments are
required to have a Person in Charge (PIC) who is a Certified Food Protection Manager. The PIC shall be a full-time employee at least 18 years of age. If the Certified Food Protection Manager is not present at the establishment, there must be a designated PIC who can demonstrate the same level of knowledge as required by the Certified Food Manager. Certified Food Manager class instructors can be found at the MA Food Protection Program website:
http://www.mass.gov/eohhs/docs/dph/environmental/foodsafety/food-safety-exam-trainers.pdf
In addition, the Certified Food Protection Manager must obtain a certificate showing that they viewed the Allergen Awareness Training video. The PIC will be responsible for training the employees on allergy awareness. The Certified Food Protection Manager and Allergy certificates shall be prominently posted in the establishment next to the food establishment permit and the Common Victualler license (if applicable). The video can be viewed on the MA Food Protection Program website: http://www.mass.gov/dph/fpp
Each food establishment having a seating capacity of 25 persons or more have on its premises, while food is being served, an employee trained in manual procedures to remove food lodged in a person’s throat. Proof of training for choke save must be available on site. All of these certificates must be obtained PRIOR to opening. Classes are offered in Newton and Framingham on a monthly basis. The class schedule can be obtain on the City of Newton’s website: http://www.newtonma.gov/gov/health/enviro/forms/food.asp A written Employee Health Policy must be submitted. The policy should consist of excluding and restricting employees on the basis of their health and activities as they relate to diseases that are transmissible through food. Written policy includes a statement regarding employee responsibility to notify management of symptoms and illness identified in the Food Code. The “FDA Employee Health and Personal Hygiene Handbook” contains forms and is a great resource that can be used. The handbook can be found at: http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or on the City of Newton’s website: http://www.newtonma.gov/gov/health/enviro/forms/food.asp
2) Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn
to a minimum scale of ¼ inch = 1 foot. Plans shall include:
• Proposed menu: List any food that will be prepared overnight, special processes, projected daily meal volume for food service operations, seating capacity and food sources.
• Food equipment schedule to include make and model numbers and listing of equipment that is certified or
classified for sanitation by an ANSI accredited certification program.
• All new or replaced equipment must be capable of cooling and holding internal food temperatures at 41ºF and below.
• All existing refrigeration equipment must be evaluated by a HVAC (Heating, Ventilation, Air
Conditioning) Specialist certifying that the equipment is capable of cooling and holding internal food temperatures at 41ºF and below. Any existing dish / glass machine must also be evaluated by an industry certified technician. Reports should be submitted as part of the Plan Review.
3) Show the location and when requested, elevated drawings of all food equipment.
• Each piece of equipment must be clearly labeled on the plan with its common name.
• Submit drawings of self-service hot and cold holding units with sneeze (breath) guards.
• Designate clearly on the plan equipment for rapid cooling, including ice baths, refrigeration and hot holding.
• Label all sinks and the designated use i.e. hand washing, utensils cleaning, food prep etc. 4) Provide on the Floor Plan: Room size, aisle space, space between and behind equipment and the placement of
the equipment. 5) Show all auxiliary areas such as storage rooms, garbage rooms, toilets, basements used for storage or food
preparation. Include and provide specifications for: Entrances, exits, loading / unloading areas and docks.
• Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases.
• Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead wastewater lines, hot water generating equipment with capacity and recovery rate, backflow prevention and wastewater line connections.
• Lighting schedule with a shield, coating, or otherwise shatter-resistant :
At least 540 lux (50 foot candle) at food prep areas where employees work with sharp or mechanical equipment.
220 lux (20 foot candle) at food service / preparation areas. 110 lux (10 foot candle) in storage areas.
• Source of water supply and method of sewage disposal.
6) A color-coded flow chart demonstrating flow patterns for:
• Food : Receiving, Storage, Preparation, Service
• Food and Dishes: Portioning, Transport, Service
• Dishes: Clean, Soiled, Cleaning, Storage
• Utensils: Storage, Use, Cleaning
• Trash and Garbage: Service Area, Holding, Storage 7) Ventilation schedule for each room. 8) Placement for mop sink / curbed cleaning facility with designated area for hanging wet mops. 9) Cabinets / Areas for storing toxic chemicals. 10) Dressing rooms, locker areas, employee rest area, coat rack. 11) Site plan for new construction.
Updated 4/9/18
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION FOR LICENSE TO MANUFACTURE FROZEN DESSERTS AND / OR
ICE CREAM MIX In accordance with the provisions of Massachusetts General Law Chapter 94, Section 65H and 105 CMR 561.000 Frozen Desserts and Frozen Dessert Mixes, the undersigned hereby applies for a license for the wholesale / retail manufacture of frozen desserts and or ice cream mix.
Please Print Legibly
Establishment Phone Number: New Establishment Existing Establishment Same as above
If not the same as above, list the location of each establishment (plant) where product(s) will be manufacture:
Applicant’s Name:
Applicant’s Address:
Owner’s Name:
Type of Business Retail Manufacturer Wholesale Manufacturer
If Wholesale Manufacturer, brand and trade name(s) of products:
Type of Product
Frozen Yogurt (not soft serve)
Frozen Yogurt (not soft-serve)
Sorbet (only if dairy-based) Other:
If Frozen Yogurt is manufactured, will it contain “friendly” cultured bacteria (live cultures)? Yes No
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Described the following Source(s) of Ingredients:
No milk or cream from a source outside of the United States, subject to the Federal Import Milk Act, 21 U.S.C §141 et seq., shall be used unless the importer has documentation to show that the exporter is in compliance with 21 CFR Part 1210.
Will a Soft-Serve Machine(s) be used? Yes – Type of Machine: No
How many machines?
Submit the specification sheets for the machine(s)
If No, describe how the product will be prepared and the storage of the final product:
Will commercially pasteurized product(s) be used? Yes No
If No, describe what will be used and how:
Will the above final product be pasteurized? Yes No
If Yes, describe the pasteurization process:
How will the refrigerated and frozen product be delivered and transported?
If transported, how will the product temperature be monitored?
How often will the surfaces and equipment be cleaned and sanitized?
What are the procedures for cleaning the equipment and surfaces and what product will be used?
How will the equipment and surfaces be sanitized?
Name and Type of Sanitizer:
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All manufactured frozen desserts produced shall have the following tests performed by a certified laboratory on its finished product monthly.
Bacterial and other Standards shall not exceed the following standards Item Standard Plate Count (SPC) Coliform
Finished Products Produced by means other than a Soft-Serve Machine
50,000/g
20/g
50,000/g
50/g
** If Frozen Yogurt contains “live cultures”, SPC laboratory testing is not required **
Copies of all test results for required tests shall be submitted directly to the Newton Health and Human Services by the certified laboratory within three (3) business days of the completion of the tests.
SUBMIT THE FOLLOWING
Completed Application for License to Manufacture Frozen Desserts and / or Ice Cream Mix
Completed Food Establishment Plan Review and Food Establishment Application (for new food establishments only) including all of the required documents. Page 6 on the Plan Review Application contains the required documents. License fee of $5.00
Note: This can be included in the total fee for the Plan Review and Food Establishment Permit Equipment Specification sheets used in the process (i.e. Soft-Serve Machine(s) etc.) For existing food establishments, provide a sketch of the processing area and / or the placement of the Soft-Serve Machine(s)
ALL APPLICATIONS MUST BE FILLED OUT COMPLETELY WITH A FEE PAYABLE TO THE “CITY OF NEWTON”
CASH AND CREDIT CARDS ARE NOT ACCEPTED AT THIS TIME ALL FEES ARE NON-REFUNDABLE
Please note that any missing information may cause a delay in the decision making process.
STATEMENT: I,
hereby certify that the above information is
correct and I fully understand that any deviation from the above without prior permission from the Newton Health and Human Services Department may nullify final approval. Additionally, I certify I will manufacture such products only from pure and wholesome ingredients and only under sanitary conditions.
Signature:
Title:
• What types of establishments are considered frozen dessert manufacturers?
1.Wholesale manufacturing plants that pasteurize raw milk and cream; 2.Wholesale manufacturers who purchase a pasteurized mix and manufacture ice cream; 3.Retail manufacturers* who purchase a pasteurized mix and manufacture ice cream, soft-serve ice cream or frozen yogurt in a “frozen dessert freezing / dispensing machine.” *It is important that the term manufacturer be understood as it pertains to frozen desserts. The term manufacturer or frozen dessert manufacturer as it appears in the regulations includes any retail establishment operating a frozen dessert freezing/dispensing machine. A “frozen dessert freezing/dispensing machine” is any machine that freezes, mixes and dispenses frozen desserts. This includes soft serve machines frequently operated at the retail level. This means that all frozen dessert manufacturers, whether wholesale or retail, require licensing by the local board of health having jurisdiction.
• What types of establishments are NOT considered frozen dessert manufacturers? 1.Stores and restaurants that purchase ice cream in bulk and scoop it, but do not make ice cream in a frozen dessert freezing/dispensing machine; 2.Retail stores that purchase ice cream or other frozen desserts in pre-packaged retail containers for re-sale to the public; 3.Vending machines that dispense packaged ice cream, novelties, etc.; and 4.“Dispensing only machines.” Dispensing only machines are machines that dispense a prepackaged ready-to-use frozen dessert. These machines do not mix or freeze a mixture. They merely dispense it. Therefore the machine is not considered a manufacturing machine.
Testing and Testing Exemptions
105 CMR 561.007 states that all manufacturers must have their frozen dessert products tested monthly by an approved laboratory. Section 561.007(F) (2) (a) refers to seven categories of frozen dessert products. The intent is to require bacteriological testing for dairy-based frozen desserts only. Dairy-based frozen desserts such as ice cream, sherbet and frozen yogurt are frozen dessert products that contain dairy ingredients. Non-dairy frozen desserts no longer require bacteriological testing. Non-dairy frozen desserts, such as sorbet, water ices, Italian ice, slush and some frozen coffee beverages are frozen desserts that do not contain any dairy ingredients. These products do not pose the same potential for supporting pathogenic organisms as do frozen desserts that do contain dairy ingredients. Therefore, testing of non-dairy frozen desserts is no longer required. According to 105 CMR 561.007 all frozen dessert manufacturers (this includes soft serve dispensing machines and ice cream barrel freezers) shall have bacteriological tests performed on at least one dairy-based frozen dessert product per month by a certified laboratory. The laboratory must submit copies of the results to the board of health upon completion of the analysis. If the SPC is above the 50.000 limit, the Person-in-Charge (PIC) shall: 1. Review the cleaning and sanitization procedures for the machine. Check the machine’s specification sheets for additional instructions and cleaning protocols for the machine. 2. Evaluate the handling of the products / ingredients. 3. If SPC is above the limit for two (2) consecutive samplings, additional sampling will be required. If the Coliform Count is above the 20/g (produced other than from a soft-serve machine) or 50/g (products from a soft-serve machine), the PIC shall: 1.Review the cleaning and sanitization procedures for the machine. Check the machine’s specification sheets for additional instructions and cleaning protocols for the machine. 2. Evaluate the handling of the products / ingredients. 3. If one (1) sample is above the required standard, resampling will be required. The presence of coliform is an indicator of inadequate operational sanitation and controls somewhere in the process. Bacteria counts slightly above the standards should be a wake -up call. It should alert the machine operator that something might not be right with cleaning, temperature, storage or handling. If a high coliform count is found (coliform count is an indicator that pathogens might be present), further testing is necessary to confirm actual pathogens.
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Helpful Recommendations
• Check all pieces of the machines components for pitting, cuts, clean ability etc. Often worn parts can lead to bacteria problems even when cleaning and sanitizing are completed properly.
• Be sure to follow the disassembling, cleaning, sanitizing and assembly of the frozen dessert machines are performed as indicated by manufacturers’ recommendation and at the required frequency. Verify the machine has been maintained properly.
• Wear gloves when assembling the machine. Be sure to wash hands properly prior to glove use. .
Codes can be found at the following websites:
City of Newton http://www.newtonma.gov/health
MA State Sanitary Code Chapter X -
Minimum Sanitation Standards for Food Establishments 105 CMR 590.000 https://www.mass.gov/files/documents/2018/10/09/105cmr590.pdf
FDA 2013 Food Code
Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063
TDD/TTY 617.796.1089
APPLICATION PERMIT TO OPERATE A FOOD ESTABLISHMENT
Complete the application below legibly. Enclose a fee payable to the “City of Newton” Cash is not accepted. Fees are non-refundable. Incomplete application may delay the permitting process.
Date: Type of Food Establishment: Mobile Stationary Temporary Permanent
Check One Check One
Will containers of Milk be sold? Yes No
If Yes, include a $10 Milk License Fee
Will Frozen Dessert(s) be Manufactured? Yes No
If Yes, complete a Frozen Dessert License Application
Will Catering be offered? Yes No
Catering is defined as Delivering AND Serving
Will there be seating? Yes No Number of Seats approved by Common Victualler (CV) License: Applicant’s Name: Title:
• To Quality for a Food Establishment Permit, an Applicant shall be an Owner or an Officer of the Legal Ownership
Mailing Address:
The Food Establishment is Legally Owned by (check one):
Association Corporation Individual Partnership Other :
Name of Legal Food Establishment Owner (as per the CV License application if applicable):
Owner’s Home Address:
Name of Contact Person (if Association, Corporation or Partnership):
Phone #: Email: • If Corporation, Association or Partnership, please attach a list of the Officer’s Names, Address and Phone Numbers
A. Name of Person Directly Responsible for the Food Establishment:
Title:
Address:
Phone #: Email:
B. Name of Person who functions as the Immediate Supervisor of the Person listed in A above:
Title: Zone Supervisor District Supervisor Regional Supervisor Other : Address:
Phone #: Email: Name of Emergency Contact Person: 24 Hour Phone #:
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Statement: I, affirm to comply with the MA Department of Public Health State Sanitary Code Chapter X – Minimum Sanitation Standards for Food Establishments (105 CMR590.000), the FDA Food Code and allow the regulatory authority access to the establishment as specified under § 8-402.11 and to the records specified under § 3-203.12, 5-205.13, 8-201.14(D)(6) and other information required by the regulatory authority. I understand that any deviation from the submitted and approved plan without prior approval from the Newton Health and Human Services Department may cause a delay in the permit process. Pursuit to M.G.L Chapter 62C, Section 49A, I hereby certify under the pains and penalties of perjury that, to my best knowledge and belief, the information provided above is true and correct and that I have filed all state tax returns and paid all state taxes required under law.
Federal Identification Number:
Food Establishment Fee: (based on Risk Category assigned) $
Milk License (only if cartons of milk are sold): $
Frozen Dessert Manufacturing
Total Amount Enclosed: $
To obtain a permit to operate a Food Establishment please submit the following:
Completed “Application for a Permit to Operate a Food Establishment”. Please print legibly. Any missing information may cause a delay in the permit process. Do not leave any blank spaces.
According to MA General Law Chapter 140 Section 2, Food Establishments that offer seating to the public for consumption on the premises requires a Common Victualler (CV) License.
Permit Fee (determined by the Newton Health and Human Services Department) made payable to the “City of Newton”. Cash is not accepted. All fees are non-refundable.
Completed “Workers’ Compensation Insurance Affidavit”. Attached a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
A copy of your Written Employee Health Policy (if New Owner or New Food Establishment).
A copy of the Person-in-Charge (PIC) Certified Food Protection Manger AND Allergy Awareness Certificates (if New Owner or Food Establishment).
Copy of Choke Save card or certificate. Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking Procedures at all times the establishment is open to the public (if New Owner or Food Establishment).
Note: The Newton Health and Human Services (HHS) Department must be notified PRIOR to the following:
• Remodeling / Changing Equipment.
• Adding Special Processes such as but not limited to: Smoking of Foods / Acidification as means of Food Preservation, Reduced Oxygen Packaging (ROP), Partial Cooking of Raw Animal Foods, and Using Time as a Public Health Control. Detail plans and specific information must be submitted for review.
Written approval must be granted by the Department prior to implementing such processes.
Food Establishment Fee Schedule The Risk Category for the Food Establishment is assigned by the HHS Department
Milk License (selling containers of Milk): $10.00 Special Process Plan Review: $50.00 Risk Category 1A (only Commercially Packaged Foods, Convenience Stores): $50.00 Risk Category 1B (Coffee Shops, Residential Kitchens, Limited Operations) $150.00 Risk Category 2: $250.00 Risk Category 3: $300.00 Risk Category 4A (Highly Susceptible Populations (HSP) such as Preschools, Hospitals, Nursing Homes; Food Establishments with Special Processes): $300.00
Risk Category 4B (Supermarkets): $400.00 The Health and Human Services Department is open M – F from 8:30 A.M. - 5:00 P.M. and until 8:00 P.M. on Tuesdays.
If there are questions, please call the Health and Human Services Department at 617-796-1420
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The Food Codes can be found at the following websites:
105 CMR 590.000 http://www.mass.gov/eohhs/docs/dph/regs/105cmr590.pdf
FDA 2013 Food Code http://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM374510.pdf
Office of Investigations Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly
Business/Organization Name:_________________________________________ __________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an organization should check box #1.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information.
Insurance Company Name:______________________________________________________________________________ Insurer’s Address:_____________________________________________________________________________________ City/State/Zip: ________________________________________________________________________________________ Policy # or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under § 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (check one): Building Department 3. City/Town Clerk 4.1. Licensing Board Board of Health 2.
5. Selectmen’s Office 6. Other _______________________________ Contact Person:_________________________________________ Phone #:_________________________________
1. I am a employer with _________ employees (full and/ or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers’ comp. insurance required] 3. We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required]** 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers’ comp. insurance req.]
Are you an employer? Check the appropriate box: Business Type (required): 5. Retail
6. Restaurant/Bar/Eating Establishment
8. Non-profit
9. Entertainment
10. Manufacturing
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.
The Department’s address, telephone and fax number: The Commonwealth of Massachusetts
Department of Industrial Accidents Office of Investigations
Lafayette City Center 2 Avenue de Lafayette,
Boston, MA 02111-1750
Tel. (857) 321-7406 or 1-877-MASSAFE Fax (617) 727-7749 www.mass.gov/dia Form Revised 7/2019
Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees. Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire, express or implied, oral or written.” An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.” MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required.” Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.”
Applicants Please fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company’s name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line.
Applicants
Slide Number 1
Slide Number 2
Slide Number 1
Slide Number 2
Institution: Off
Daycare: Off
New: Off
Remodel: Off
Conversion: Off
NA No seats: Off
Area of Facility ft²:
Number of Floors:
Breakfast:
Lunch:
Dinner:
Refrigerator Storage:
Freezer Storage:
Dry Storage:
Identify the location and containers that will be used to store bulk food products rice sugar etc:
List all foods that will be cooked and cooled:
1:
2:
3:
List all foods that will be cooked cooled and reheated:
1_2:
2_2:
3_2:
List all foods that will be hot held prior to service:
1_3:
2_3:
3_3:
undefined_6:
undefined_7:
Location:
undefined_8:
undefined_9:
Location_2:
Reduced Oxygen Packaging ROP Use of Additives to Render a Food NonTCS Acidification Curing and: Off
If yes in addition to this application complete the Hazard Analysis Critical Point Plan Review Application: Off
If yes complete the Request for Variance Form including the Granted Variance Section of the form: Off
undefined_10: Off
undefined_11: Off
Ready to Eat Foods RTE eg salads cold sandwiches and raw molluscan shellfish:
Produce:
Poultry:
Meat:
Seafood:
Yes_11: Off
Explain how the basement will be used for food preparation:
1_4:
2_4:
What is the capacity and location of the water heater:
Will an ice machine be installed: Off
If yes where:
Will the largest pot pan fit into each compartment of the 3compartment sink: Off
If No describe the cleaning method that will be used:
1_5:
2_5:
Describe the location type of device used for air drying clean equipment:
1_6:
2_6:
Will the machine be equipped to automatically dispense detergents and sanitizers: Off
undefined_14: Off
Visual: Off
Audible: Off
What type of sanitizer and the brand name will be used on food contact surfaces:
Chlorine: Off
Quaternary: Off
If no where will employees store personal items:
Identify the storage location for poisonous or toxic materials chemical storage:
Identify how grease will be disposed:
How often will the grease traps be cleaned:
Identify the location of grease storage containers:
REFUSE:
If yes describe where:
Identify how and where garbage cans and floor mats will be cleaned:
undefined_18: Off
Name of company used for dumpster pickup:
Describe the surface and location where the dumpster garbage will be stored outside:
Is there a Written Employee Health Policy for ALL Employees:
undefined_19: Off
WALLSGarbage Refuse Storage:
CEILINGGarbage Refuse Storage:
FLOORMop Service Sink:
WALLSMop Service Sink:
CEILINGMop Service Sink:
FLOORWare washing Area:
WALLSWare washing Area:
CEILINGWare washing Area:
FLOORWalkin Refrigerators Freezers:
WALLSWalkin Refrigerators Freezers:
CEILINGWalkin Refrigerators Freezers:
undefined_22: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow2:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow3:
undefined_23: Off
undefined_24: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow7:
undefined_25: Off
undefined_26: Off
undefined_27: Off
A copy of Certified Food Managers Certificate Allergy Awareness Certificate Choke Save Training Certificate:
Certified Food Managers Certificate: Off
Allergy Awareness Certificate: Off
undefined_28: Off
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow14:
PLEASE ENCLOSE THE FOLLOWING DOCUMENTSRow15:
undefined_29: Off
STATEMENT I:
Print Name:
Date Submitted:
Fee Received:
2_7: Off
3_4: Off
4A: Off
4B: Off
1_7:
2_8:
Custard:
undefined_34: Off
undefined_40:
Other_2:
If Frozen Yogurt is manufactured will it contain friendly cultured bacteria live cultures Yes:
undefined_41: Off
Sources of Ingredients 1:
Sources of Ingredients 2:
Sources of Ingredients 3:
be used unless the importer has documentation to show that the exporter is in compliance with 21 CFR Part 1210:
Yes Type of Machine: Off
No_27: Off
1_8:
2_9:
If No describe what will be used and how:
1_9:
2_10:
1_10:
2_11:
undefined_44:
How will the refrigerated and frozen product be delivered and transported 1:
How will the refrigerated and frozen product be delivered and transported 2:
undefined_45:
If transported how will the product temperature be monitored 1:
If transported how will the product temperature be monitored 2:
undefined_46:
How often will the surfaces and equipment be cleaned and sanitized:
undefined_47:
What are the procedures for cleaning the equipment and surfaces and what product will be used 1:
What are the procedures for cleaning the equipment and surfaces and what product will be used 2:
undefined_48:
Name and Type of Sanitizer:
Completed Application for License to Manufacture Frozen Desserts and or Ice Cream Mix: Off
Completed Food Establishment Plan Review and Food Establishment Application for new food establishments only: Off
License fee of 500: Off
Equipment Specification sheets used in the process ie SoftServe Machines etc: Off
For existing food establishments provide a sketch of the processing area and or the placement of the: Off
STATEMENT I_2:
Catering is defined as Delivering AND Serving: Off
Will there be seating Yes: Off
No_33: Off
Applicants Name_3:
To Quality for a Food Establishment Permit an Applicant shall be an Owner or an Officer of the Legal Ownership:
Phone Number_2:
Name of Emergency Contact Person:
affirm to comply with the MA Department of Public Health State Sanitary Code:
Federal Identification Number:
undefined_55:
undefined_56:
Special Process Plan Review:
Risk Category 2:
Risk Category 3:
