TOWN OF MARSHFIELD
Board of Health
870 Moraine Street
Marshfield, MA 02050
781-834-5558 fax 781-837-6047
FOOD HANDLER PERMIT
Renewal APPLICATION FORM
Please complete, sign and return this form to the Health Department along with FEE, State required Workers Compensation Insurance Affidavit form and a copy of current food certification(s).
Permits will not be issued unless all forms are returned.
Total fee for 2008_________ Months of operation____
Type of Permit: Retail Food_____ Mobile____ Frozen Desserts____ Restaurant Food _____
1 –25 seats ______ 25 – 50 seats ______ 50 – 100 seats ______ Over 100 seats ______ N/A____
*PLEASE PRINT
Name of establishment______________________________________________________________
Name of Certified Professional Food Manager___________________________________________
(If different from last year, please enclose a copy of Manager’s certification)
Business address_______________________________________________________________
Business Telephone #__________________________Fax # ________________________
Mailing address____________________________________________________________________
(If different from above)
Hours of operation__________________________________________________________________
Contact Person____________________________________________________
Emergency Phone #_______________________________Cell Phone #________________________
Pursuant to M.G.L. Ch 62C, Sec.49A, I certify under penalties of perjury that I, to my best knowledge and belief, have filed state tax returns and paid all state taxes required under law. (Must be filled out and signed)
Signature of Individual or Corporate Name______________________________________________
By_________________________________________________________
Corporate Officer (If applicable)
If Corporation or partnerships, give name, title, and home address of officers or partners.
NAME TITLE HOME ADDRESS
Name & address
State of incorporation________of local agent_________________________________________________
I HEREBY STATE THAT ALL ANSWERS ARE CORRECT AND UNDERSTOOD OR HAVE BEEN CORRECTED.
Signature__________________________________________________Date____________________
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