TOWN CLERK’S OFFICE, NORTH ANDOVER, MASSACHUSETTS MOBILE FOOD LICENSE APPLICATION FOR TAKEOUT FOOD SERVED BY MOBILE FOOD VENDORS (PLEASE TYPE OR PRINT CLEARLY) Name of Applicant: ___________________________________________________________ Date: ____________________________ D.O.B: ______________ S.S.N: _____________________ Dr. Lic #: _____________________Fed.ID#: ________________________ Name of Business: ___________________________________________________________________________________________ Business Address: ___________________________________________________________ Business Telephone: _______________ Home Address: ______________________________________________________________ Cell Phone: ______________________ Hawkers & Peddlers License #_____________________________________

Please provide the following for each owner and all employees : (if more space is needed use back of form) Name

Social Security Number

CORI Authorization

SORB Authorization

Y

N

Y

N

Y

N

Y

N

N

Y

N

Y Application Review (Required Before Mobile Food License Decision)

PROVIDE THE FOLLOWING INFORMATION: What will be the hours of operation? _______________________________________________________________________________ What Address will the vehicle originate from: ________________________________________________________________________ What provisions have been made for trash removal? __________________________________________________________________ What provisions have been made for restroom facilities? _______________________________________________________________ Have you applied to the Board of Health for a food permit? : _____ (YES) _____ (NO) Will you be seeking permission for the following items: Free-standing Sign:____ (YES) ____ (NO) Table or Chairs: ____ (YES) _____ (NO) Music/Entertainment :______ (YES) _____ (NO)

PLEASE ATTACH A SEPARATE LIST OF THE PRIVATE LOCATIONS WHERE THE MOBILE FOOD VEHICLE WILL BE DEPLOYED AND ATTACH A SKETCH OF HOW THE VEHICLE WILL BE POSTIONED AND OTHER DETAILS OF THE AREA TO BE LICENSED. I, the undersigned, state that the information provided in this application and associated attachments is true and accurate to the best of my knowledge. Print Name: _________________________________ Signature: _________________________________ Date: _________________

Note: No Mobile Food License will be approved until the applicant addresses all issues and concerns to the satisfaction of the Board of Selectmen. A MFL will NOT be issued until all required inspections have been conducted, permits granted, and final approvals given.