Permit #_______ Residential Kitchen Application Fee $________

Name_________________________

Address ______________________________

Telephone #_____________________

Distribution:

Retail____ wholesale______

Selling foods: from home____ at farmers market____ Other__________________________________

*Please attach a menu of foods to be prepared in residential kitchen, include ingredients, purchasing sources, and methods 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 testing may be required

Town sewer_____ Septic system____ Title 5 inspection may be required

Requirements:

Only non-potentially hazardous foods and foods which do not require refrigeration shall be prepared in or distributed from a residential kitchen. Only immediate family members may assist in preparation and distribution. Pets may not be present during food preparation and 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. All foods sold shall be labeled containing ingredients, allergens and health claims.

A food establishment permit will be required for food preparation and distribution from a residential kitchen for retail sale and shall comply with minimum requirements of 105 CMR 590.002 through 105 CMR 90.009, as well as administrative enforcements of 105 CMR 590.012 through 105 CMR 590.021.

I certify that I am familiar with 105 CMR590.00 Minimum Sanitation 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:

Reviewed regulations______ Given pamphlet info_______ Inspection done_____

Septic system flow capacity_______ Menu attached______ Permit mailed______

Dishwasher temp log______ Returned thermometer__ / ___ Title5 received_____

Well water test results_______ Title 5 inspection needed_______