Mayor Alex Morse Brian D Fitzgerald, Director

City of Holyoke Board of Health

APPLICATION FOR TEMPORARY FOOD PERMIT

Permit Expires Two (2) WEEKS After Issue Date

Location of unit for Operation______

(Street or site location)

Today’s Date ______FEE: $50.00 (CHECK#______) *NO CASH*

Date(s) of event and hours of operation: ______Hours:______

______Hours:______

Name of Establishment:______

Name of Owner/Corp. President: ______Title: ______

Owner’s Address: ______

City, State, Zip: ______

Owner Home Phone: ______

Mailing Address: (if different) ______

Email: ______Cell phone/emergency #______

1.  Before completing this application, read Food Safety at Temporary Events and the Temporary Food Establishment

“Are You Ready” Checklist (BOTH ARE ENCLOSED) Have you read this material? (Circle one) yes no

2.  Type of Food Station Set-Up (Check one)

£  Vehicle with Roof (Truck, Van, etc.) – No Open Air Permit Needed

Any of the Following Need to Obtain an Open Air Permit from the License Board

£  Mobile Food Cart with Umbrella £Other (Describe)______

£  Tables, Tents, Umbrellas & Equipment

3.  Menu: List all items you intend to serve. Any changes must be submitted in writing and approved by the Board of Health at least 5 days prior to the event.

______

4. Will all foods be prepared at the temporary food establishment booth? (Circle one) yes no

Yes 1. Fill out Section B below

No 2. Fill out both A and B below

Include dates and times of food preparation and attach a copy of the BASE OF OPERATIONS food permit.

SECTION A: At the approved kitchen:

5. Attach copies of

a. ServSafe Food Handlers Certificate and Allergen Certificate

b. Copy of Food Establishment Permit of approved kitchen to be used to prepare any foods.

6. List each food item prepared, and for each item check which preparation procedure will occur.

DATE/

TIME

/ FOOD ITEM /

THAW

/ CUT/
ASSEMBLE /

COOK

/ COLD
HOLDING /

REHEAT

/ HOT
HOLDING

OVER→

SECTION B: At the booth

FOOD ITEM / THAW / CUT/
ASSEMBLE / COOK / COLD
HOLDING / REHEAT / HOT
HOLDING

Note: If your food preparation procedures cannot fit into the tables, please list all of the steps in

preparing each menu item on an attached sheet.

7. Food source(s) list food supplies: ______

Source and storage of water/ice: ______

Storage and disposal of wastewater: ______

Storage and disposal of trash: ______

Means for Hand-washing: ______

8. If a Temporary Food Operation draw a sketch of the booth and equipment below:

I certify that I am familiar with 105 CMR 590.000 Minimum Sanitation Standards for Food Establishments - Article X and the above-described establishment will be operated and maintained in accordance with regulations.

Pursuant to M.G.L., Chapter 62c, Section 49a, I certify, under then penalties of perjury that, I to the best of my knowledge and belief, have filed all state tax returns and paid all state taxes required under law.

**Application fee is nonrefundable **Fee due with application

Applicant’s Signature: ______Date: ______

application.for.temporary.permit

Mayor Alex Morse Brian D Fitzgerald, Director

City of Holyoke Board of Health

BASE OF OPERATIONS FORM

TO: Mobile Food Vendors

FROM: Brian D. Fitzgerald, BOH Director

DATE: February 5, 2016

RE: Base of Operations- FOR MOBILE FOOD UNIT OR PUSHCART

According to 105 CMR 590.009 State Sanitary Code, it is required that all mobile units must operate from a fixed, licensed food establishment, or food processing plant, and shall report at least daily to such locations for all food, water, supplies, and for all cleaning and servicing operations. Mobile food operators shall retain the list of ingredients and the receipt for all bulk foods, which must indicate that name of the food item, the date purchased, and the name of the approved food source licensed in accordance with 105 CMR 500.000.

Therefore, in addition to completing the annual food permit application, workers’ compensation form, you must also fill out in its entirety, the attached base of operation form and attach a copy of the “base of operations” food permit. A permit will not be issued to any mobile unit, with these forms not completed and reviewed by the Board of Health.

Please be advised that unlicensed residential kitchens can not be used as a base of operations.

Thank you for your anticipated compliance.

Mobile Food Unit Permit Holder:

Owner’s Name: ______

Address: ______

City/Town: ______

Telephone: ______

Food Product(s) Being Sold: ______

Base of Licensed Kitchen Operations/Permit Holder

Business Name: ______

Base of Licensed Kitchen Address: ______

City/Town: ______

Telephone: ______

Mayor Alex B. Morse Brian D. Fitzgerald, Director

City of Holyoke Board of Health

ATTENTION

ALL MOBILE UNIT/PUSHCART VENDORS

An Open Air Vendor License is required if you will be operating in a fixed area (i.e. you will not be moving your unit throughout the City). This license is obtained from the Holyoke Licensing Board located in the 4th floor of the Annex Building (Tel. # 413-322-5599) for $100.00 for an annual permit or $30.00 for a temporary one.

Per City Ordinance, you are required to obtain a Hawkers & Peddlers License if you are operating at any place within the City other than from a fixed place of business (i.e. you will be moving your unit throughout the City). This license can be obtained from the Holyoke Police Department for $100.00. For further information on this license, you may contact the Police Department at 536-6431.

You are not required to obtain an Open Air Vendor License or a Hawkers & Peddlers License if you possess a State License.

Remember you need either an Open Air Vendor License OR a Hawkers & Peddlers License-NOT BOOTH!!!

If you have any questions, please call 322-5595.

Thank you.

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