Form Center

2. Establishment's Information
4. Establishment Name (dba):*
5. Establishment Tel. #:*
7. Establishment Address:*
9. Mailing Address:*
11. Email Address:*
13. Applicant's Information
15. Name and Title:*
17. Address:*
18. Tel. #:*
20. Owner's Information
22. Name and Title (if different from applicant):
24. Address:
26. Food Permits (check all that apply)*

    1. Food Service Establishment
    2. Retail Food
    3. Catering
    4. Mobile Food Unit
    5. Other
28. 24 Hour Emergency Contact-Person In Charge
30. Name and Title:*
32. Address:*
33. Tel. #:*
35. 24 Hour Emergency #:*
36. Email Address:*
38. Food Establishment Information
40. Days and hours of Operation:*
41. # of Seats:*
43. Name of Person in Charge Certified in Food Protection Management:*
45. Person Trained in Food Allergen Awareness:*
47. Person Trained in Anti-Choking Procedures (if 25 or more seats):*
49. In Accordance with 105 CMR 590.003 (A) 590.009 and 590.003 (B)

    
    

50. Please attach Current Food Protection Manger certification
51. Please attach current MA Allergen Awareness Certificate
53. Please Attach Current CPR/Choke Saver Certificate
54. Please Attach Current Worker Comp/MA Affidavit

56. FOOD PERMIT	FEE
    Farmer's Market - Non-restaurant	$75
    Farmer's - Restaurant	$35
    Farmer's - Site	$25
    Food Service Establishment	$150 (< 50 seats) $250 (51 - 199 seats) $350 (>200 seats)
    Mobile Food Service	$150
    Residential Kitchen	$100
    Retail Food	$125 (0 - 5K ft2) $150 (5k - 15K ft2) $300 (> 15K ft2)
    Scallop Shanty	$50

    Temporary Food: Bake Sale Nonprofit Fundraiser (no food prep)	$30 w / o TCS $50 w / TCS $10 for 10 events $100 for 5 events
    Catering	$150
    Supermarket	$300
    Plan Review	$150
    Daycare	NA
    Limited Service / Retail	$50

58. *Frozen Dessert Manufacturing Permit - $150 (Annually)
60. Water Source*

    1. Town
    2. Well* (annual test required)
61. Sewage Disposal*

    1. Town Sewer
    2. Septic
63. I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the Food Establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code.
65. FULL NAME OF APPLICANT*
67. PLEASE MAKE ALL CHECKS PAYABLE TO TOWN OF NANTUCKET

    
    

69. Pursuant to MGL Chapter 62C, section 49A, I certify under the penalties of perjury that, to my best knowledge and belief, complied with the law of the Commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting child support.

71. Full Name of Corporate Representative (i.e. President, CFO. COO):*
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field