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2. Establishment Name*
3. Establishment Phone #*
5. Establishment Address*
6. Days & Hours of Operation*
8. Mailing Address ( if different)
10. City
11. State
12. Zip
14. Owner Name & Title*
16. Owner's Home Address*
    Street, Town/City, State & ZIp Code
18. Owner Phone #*
19. 24 hr Emergency #*
21. Establishment Owned By:*
    -- Select One --IndividualAssociationCorporationPartnershipOther (Specify in next box)
23. If a corporation or partnership, give name, title and home address of officers or parterns
25. Name & Title of Person Responsible for Daily Food Operations (Full Time Person in Charge/PIC, owner, manager, etc.)*
26. 24 Hr. Phone # for PIC*
27. Email address for PIC*
29. Name(s) of person(s) who are Certified Food Protection Managers
    NEW establishments submit copies of certificates to healthdept@winchester.us
31. 1. Name of Certified Food Protection Manager*
32. 1. Expiration Date*
34. 2. Name of Certified Food Protection Manager
35. 2. Expiration Date
37. Name of Person(s) who have received Allergen Awareness Training
    NEW establishments submit copy of certificate
39. 1. Name with Allergen Awareness Training*
40. 1. Expiration Date*
42. 2. Name with Allergen Awareness Training
43. 2. Expiration Date
45. No. of Seats in Establishment*
46. Person Trained in Anti-Choking Procedures (if 25 seats or more)*
    -- Select One --YesNoNot Applicable

    If yes, NEW establishments must submit copy of training certificate(s)
48. Do you have a plan in place for excluding and restricting food employees from working if they become ill, including, but not limited to, a "Food Employee Reporting Agreement?"*
    -- Select One --YesNo
50. Do you have a plan in place in case of emergency (power outage, sewer back-up, water service interruption or fire)? A plan would include keeping the food safe and prevent any food-borne illness to the public.*
    -- Select One --YesNo
52. If Supermarket/Large Retail Operation (Category 4A), provide square footage of establishment
54. Permit & Fees (Note: TCS = Time/Temperature Control for Safety Food)*
    -- Select One --Risk Category 1: $75 (Pre-packaged food with ltd TCS or Residential Kitchen)Risk Category 2: $150, plus $1.00 per seat (fast service operations, ltd menu, schools) Note: no charge for public schoolsRisk Category 3: $200, plus $1.00 per seat (full service restaurant, complex menu or other)Risk Category 4: $250, plus $1.00 per seat (serves highly susceptible population, preschool or other)Risk Category 4A: $150, plus $1.00 per sq. ft. (Supermarket/Large Retail)House of Worship Kitchen: $35Farmer's Market - Multi Vendor (Non-TCS): $150

    Annual inspections will be conducted based on the risk level of your establishment and the number of inspections will correspond to the risk category number. These inspections will be unannounced and may take place during evening hours, on a weekend or holiday and during food preparation times. The expectation is that the PIC for the establishment will meet with the Health Inspector for the inspection. For more information, see FC 8-402.11
56. LATE LICENSE RENEWAL FEE: $10 PER EACH DAY OVERDUE
58. 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 590.00 and the federal Food Code. For copies of applicable regulations, go to: www.winchester.us
60. Signature of Applicant*
    Typing in your name will be considered an electronic signature.
61. Print name, if different than owner
63. Pursuant to MGL Ch. 62C, sec. 49A, I certify under penalties of perjury that I, to my best knowledge and belief, have filed all State tax returns and paid State taxes required under law.
65. Social Security # or Federal ID #:*
66. Signature of Owner or Corporation Name*
    Typing in your name will be considered an electronic signature.
68. PAYMENT OPTIONS
    Payment can be made online by clicking on the link below, or a check made payable to "Town of Winchester," can be mailed to: Health Dept., 71 Mt. Vernon St, Winchester MA 01890. Permit is not considered complete until all documentation is received, and fee is paid. Permit will not be processed until application is complete and fee is paid.
70. Online Payment
    Food Establishment Permit

    After payment is complete, you have to return to this page and submit your application.
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72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field