Other legal entity ______________
59 Falmouth Town Hall Square, Falmouth MA 02540 • (508)495-7485 • health@falmouthmass.us
Anti-Choking Certification(s)
Certificate of Insurance for WC Policy
11) Owner Email Address (if different from applicant):
Email Address:
Email Address:
Town Sewer
16) Water Source:
DEP Public Water Supply # (if applicable):
17) Sewage Disposal (check all that apply):
On-site Septic
Grease Trap (if required by Health or Plumbing Dept.)
Food Establishment Information
Date Received
Date Inspected
Approved By
Permit # Issued
Annual Food Establishment Permit Application
Application must be submitted at least 30 days before the planned opening date
Food Safety Manager Certficate(s)
Allergen Awareness certificate(s)
7) Applicant Address:
4) Est. Telephone #:
5) Email Address:
Supporting documentation included:
6) Applicant Name & Title:
Workers' Compensation Policy Affidavit
1) Establishment Name:
2) Establishment Address:
3) Establishment Mailing Address (if different):
14) Person Directly Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager, etc.)
Name & Title:
Telephone #:
8) Applicant Telephone #:
24 Hour Emergency #:
9) Owner Name & Title (if different from applicant):
10) Owner Address (if different from applicant):
An individual
A partnership
12) Establishment Owned By:
An association
A corporation
Emergency Tel. #
Telephone #:
15) District or Regional Supervisor (if applicable)
Name & Title:
Food Service ( ______ Seats)
Seasonal - Dates of Operation:
Signature of Applicant
Residential Kitchen for Bed and Breakfast Home
Use of Process Requiring a Variance and/or HACCP
Plan (ex. bare hand contact of TCS food, time as a public health control etc.)
Other - Please Describe:
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 590.002 and all other applicable law. I have been instructed by the Board of Health on how to
obtain copies of 105 CMR 590.002 and the Federal Food Code.
Prepares Food/Single Meals for Catered Events or
Institutional Food Service
Vacuum Packaging/Cook Chill
Offers RTE TCS food in Bulk Quantities
Juice Manufactured and Packaged for Retail Sale
Ice Manufactured and Packaged for Retail Sale
Retail Sale of Out-of-Date or Reconditioned Food
Customer Self-Service
Hot TCS food Cooked and Cooled or Hot Held for
More than a Single Meal Service
TCS and RTE Foods Prepared for Highly Susceptible
Population Facility
Sale of Raw Animal Foods Intended to be Prepared by
Offers Raw or Undercooked Food of Animal Origin
Reheating of Commercially Processed Foods for
Service within 4 hours
Customer Self-Service of Non-TCS and Non-Perishable
Foods Only
Preparation of Non-TCS food
24) Food Operations (check all that apply):
Other (Please Describe):
Residential Kitchen for Retail Sale
Frozen Dessert Manufacturer
Food Service - Institution
Retail ( _______ Sq. Ft.)
Food Service - Takeout
Preparation of TCS food for Hot and Cold Holding for
Single Meal Service
Sale of Commercially Pre-Packaged Non-TCS food
Sale of Commercially Pre-Packaged TCS food
Delivery of Packaged TCS food
TCS Cooked to Order
Non-TCS - non-time/temperature control for safety food (no time/temperature controls required)
RTE - ready-to-eat foods (ex. Sandwiches, salads, muffins etc. which need no further processing)
23) Length of Permit (check one):
TCS - time/temperature control for safety food (time/temperature controls required)
Food Delivery
If yes, please enclose certifications of all personnel trained in Anti-Choking Procedures.
20) Name(s) of Current Person-in-Charge Certified in Food Protection Management:
Required in accordance with 105 CMR 590.002; Must be Full Time Equivalent; there is a 90 day grace period after certificate expires for renewal purposes.
21) Does your establishment have 25 seats or more: YesNo
18) Days and Hours of Operation:
19) No. of Food Service Employees:
22) Establishment Type (check all that apply):
Bed & Breakfast Establishment
Applicant Information Please Print Legibly
Business/Organization Name:_________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers’ compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers’ compensation insurance for my employees. Below is the policy information.
Insurance Company Name:______________________________________________________________________________
Insurer’s Address:_____________________________________________________________________________________
City/State/Zip: ________________________________________________________________________________________
Policy # or Self-ins. Lic. # Expiration Date:
Attach a copy of the workers’ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen’s Office
6. Other _______________________________
Contact Person:_________________________________________ Phone #:_________________________________
1. I am a employer with _________ employees (full and/
or part-time).*
2. I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers’ comp. insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers’ comp. insurance required]**
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers’ comp. insurance req.]
Are you an employer? Check the appropriate box:
Business Type (required):
5. Retail
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. Entertainment
10. Manufacturing
11. Health Care
12. Other _____________________________
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Workers’ Compensation Insurance Affidavit: General Businesses.
Information and Instructions
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
The Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Form Revised 02-23-15
Massachusetts General Laws chapter 152 requires all employers to provide workers’ compensation for their employees.
Pursuant to this statute, an employee is defined as “...every person in the service of another under any contract of hire,
express or implied, oral or written.”
An employer is defined as “an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.”
MGL chapter 152, §25C(6) also states that “every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.”
Additionally, MGL chapter 152, §25C(7) states “Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.”
Please fill out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company’s name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.