Application For Food Establishment Form - Adams County Health Department
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1ADAMS COUNTY HEALTH DEPARTMENT
330 Vermont Street • Quincy, Illinois • 62301
(217) 222-8440
Application for Food Establishment
Name of Business:________________________________________________________________________
Address:________________________________________________________________________________
Street
City
Zip
Telephone Number of Business:____________________ Fax Number of Business:__________________
Email Address ___________________________________________________________________________
Hours of Operation _______________________________________________________________________
Billing Address (if different than business address:)__________________________________________
__________________________________________
Individual
Partnership
Corporation
_____________________________________________
Name, Address & Phone #’s of
owner(s)
Name of Emergency Contact (if different than owner(s)_________________________________________
Emergency #’s Phone: _________________ Cell: _______________________ Fax:_________________
Application is hereby made for a Food Handler’s Certificate of Compliance to operate. By this application it is agreed that the
establishment will comply with the provisions of the Adams County Retail Food Sanitation Ordinance applicable to this type of food
handling establishment. It is further agreed that said food service establishment shall be open to inspection by the Adams County
Health Department.
_______________________________________________
________________________________
Signature of Owner(s)
Date
Office Use Only
TYPE OF BUSINESS
01
Restaurant
11
Retail Confectionery
02
Tavern with Food Preparation
12
Retail Bakery
03
Tavern with Prepackaged Food Only
13
Retail Fruit & Vegetable Market
04
School Food Service
14
Catered – Serving Location
05
Institutional Food Service
15
Day Care
06
Snack Bar
16
Bed & Breakfast
07
Mobile Food Operation
17
Caterer
08
Food Vending Commissary
18
Conv. Store With Food Preparation
09
Retail Food Store
19
Club or Fraternal Organization
10
Retail Fish Market
20
Other:
RISK ASSESSMENT
Certificate of Compliance Number_____________________
___ High (Category I)
Amount ___________________________________________
___ Medium (Category II)
Date: _____________________________________________
___ Low (Category III)
Check ________
Cash _________
5-2011
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Parent category: Legal