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Food Establishment Permit Application

  1. No permits will be issued until payment has been received in full and processed by the staff of the City of Gardner Health Department

  2. If Applicable

  3. Owner, person in charge, supervisor, manager, etc

  4. If applicable

  5. If Applicable

  6. Does your establishment have people trained in anti-choking procedures

  7. Location

  8. Time/ Temperature Controls Required

  9. No Time/Temperature Controls required

  10. Sandwiches, Salads, Muffins, etc., which need no further processing

  11. Food Operations

    Check all that apply

  12. Describe

  13. 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 Code

  14. Pursuant to MGL Ch 62C, Sec 49A, I certify under the penalties of perjury that I, to the best of my knowledge and belief, have filed all state tax returns and paid state taxes required by law.

  15. No permits will be issued until payment has been received in full and processed by the City of Gardner Health Department. All checks must be made out to "City of Gardner" and sent to Gardner Board of Health, Gardner City Hall Rm 29, 95 Pleasant St. Gardner, MA 01440

  16. 0-24 Seats: $100; 25-50 Seats: $150; 51+ Seats: $200 (maximum fee); Seasonal: $100; Temporary: $20/day

  17. $150

  18. $100

  19. $150

  20. No Charge- Non Profit Organization

  21. $100

  22. $25

  23. $25

  24. Leave This Blank:

  25. This field is not part of the form submission.