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Food Establishment Permit Application

  1. Food Establishment Permit Application

    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. Applications must be submitted at least 30 days before the planned opening date

  3. If Applicable

  4. If Owner is different from Applicant

  5. Person directly responsible for the daily operation

    Owner, person in charge, supervisor, manager, etc

  6. District or Regional Supervisor

    If applicable

  7. If Applicable

  8. For Establishments with 25 seats or more

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

  10. Location

  11. Definitions:

  12. Potentially Hazardous Food

    Time/ Temperature Controls Required

  13. Non Potentially Hazardous Foods

    No Time/Temperature Controls required

  14. Ready to Eat Foods

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

  15. Food Operations

    Check all that apply

  16. Describe

  17. Certification and Electronic Signature

    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

  18. 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.

  19. Payment:

    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

  20. Fee Schedule:

  21. Food Service/Restaurant

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

  22. Seasonal Mobile Food Permit

    $150

  23. Seasonal Food Permit

    $100

  24. Mobile Food Permit

    $150

  25. Food Pantry Service

    No Charge- Non Profit Organization

  26. Frozen Dessert, Ice Cream, Yogurt (Mfg'ers Only)

    $100

  27. Limited Retail food service only- less than 10 SqFt only wrapped pre-packaged items

    $25

  28. Limited Food Service- Stationary; heating wrapped pre-packaged items only

    $25

  29. Leave This Blank:

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