Bed and Breakfast

Food Establishment Application

Permit #________ Fee $________

Name of Establishment and Owner______________________________________________

Address of Establishment_______________________________

Telephone number_____________________________

______ Continental breakfast only (purchased pastry, juice)

_______ Complete breakfast served

_______ Food Management Certification (required if serving a full breakfast-please attach a copy)

_______ Number of bedrooms for business establishment

_______ Maximum number of guests allowed

________________________________________________________________

*Please attach a menu of foods to be prepared including ingredients, purchasing sources and method of preparation.

Dishwashing:

Manual_____ Automatic * ______ Type of sanitizer used_______

*Record and keep a log of the final rinse cycle temperature. Thermometer available from BOH

Town Services:

Town water_____ Private well______ Water quality test may be required

Town sewer______ Septic system_____ Title 5 inspection may be required

Requirements:

Food handling practices for Potentially Hazardous foods ( PHF) is prohibited. (PHF are foods requiring refrigeration), also cooling and reheating prior to service, hot holding for more than 2 hours and the serving of leftovers are also prohibited. Cooking facilities or kitchen may not be available for guests. Pets may not be present during food preparation and kept out of dining area, also laundry facilities (if located in kitchen area) may not be used during food preparation. Food contact surfaces shall be smooth and made of non-absorbent materials. A food establishment permit is required for food preparation and shall comply with the minimum requirements of 105 CMR 590.00.

I certify that I am familiar with105 CMR 590.00 Minimum Standards for Food Establishments- Article X. The above mentioned establishment will be operated and maintained in accordance with the regulations.

Applicant Signature_________________________________________ Date __________________________

BOH use only

Inspection done_____ Copy of Serv-safe Certificate____

Well water test results______ Reviewed regulations_________

Dishwasher temp log__/ ___ Title 5 inspection needed_______ Title 5 received_____

Returned thermometer____ Septic system flow capacity_____ Permit mailed ______