Form Ehs - New Food Service Establishment Permit Application printable pdf download

NEW FOOD SERVICE ESTABLISHMENT

Prorated Fee amount:

____________________

For

(minus) Site Eval fee paid: ____________________

PERMIT APPLICATION

Office

Balance Due: _________________

Use

Environmental Health Services

Phone: (607) 737-2019

Only

______________

_____________

Date Paid:

Recpt #:

Fax:

(607) 737-2059

CHEMUNG COUNTY HEALTH DEPARTMENT

Approved by: __________________

103 Washington Street, Post Office Box 588

Effective: ______________ Expir: _____________

Elmira, New York 14902

email: EHS@co.chemung.ny.us

It is a violation of the NYS Sanitary Code and the Chemung County Sanitary Code to operate a Food Service Establishment without a valid permit.

Please type or print the required information and return the completed application and fees to the above address at least 21 days before the first day of

operation. Failure to do so may delay issuance of your permit to operate. Make checks payable to: Chemung County Health Department

For Office Use Only:

ESTABLISHMENT TYPE

(Check all that apply):

____________________

New FS Estab. #:

Restaurant

Restaurant -

Catering -

- Full Service

Fast Food/Light Meals

Off Premise

Op ID #:_________________________________

Tavern –

Mobile Unit/Pushcart

School

Beverages & snacks only

Date C of O issued: _______________________

Church/Fire Dept

Vending machines

Other: ___________________

Risk Level Assigned:

High

Med

Low

SECTION A - FACILITY INFORMATION (Entire section must be completed by all applicants)

Facility Name: ______________________________________________________________ Phone: __________________________

Please indicate where you would like permits & renewal paperwork sent -

Facility Address:_________________________________________

Mailing Address:________________________________________

City, State, Zip: _________________________________________

In Operation

Year-round

Seasonal

(check one)

(no more than 6 months) - Opening Date: ___________ Closing Date: ___________

Days/Hours of Operation:

Seating Capacity: _______________

(Please list all days and hours that you are open for business):

Water supply (check one):

Public

Private (If Private - Type of Water Disinfection:

Chlorinated

UV Radiation

None)

Sewage System (check one):

Public

Private

Is any food prepared at another location?

Yes, ( If Yes, state location: ______________________________________________)

SECTION B – OWNER/OPERATOR INFORMATION

Legal Operator or

Operating Corporation: ___________________________________________________________ Email Address (required): ___________________________________

Operator Address: __________________________________________________________________________

City, State, Zip: ______________________________

Phone: __________________________________

Cell Phone: _________________________________________

Fax #: __________________________________

>>> Is Owner information the same as the Operator information listed above?

Yes

No >> If No, please complete the section below:

Owner Name: ___________________________________________________________________ Email Address: ___________________________________________

Owner Address: ____________________________________________________________________________

City, State, Zip: ________________________________

Phone: __________________________________

Cell Phone: _________________________________________

Fax #: ___________________________________

Manager’s Name: _____________________________________________

Phone: __________________________ Cell Phone: _____________________________

>>> Is owner/operator a Corporation or Organization?

Yes

(If YES, Please fill out Section G on back).

SECTION C – WORKER’S COMPENSATION & DISABILITY INSURANCE INFORMATION

This is to certify, under the penalties of perjury, that the above described operation either has Worker's Compensation and Disability Benefits coverage

when required by law OR has completed CE-200 stating that such coverage is not required (see attached instructions on how to complete this form).

Worker’s Compensation Insurance (Attach proof of Insurance form to application). Check which form is provided as proof:

Form C-105.2

Form U-26.3

Form SI-12

Form GSI-105.2

(note: Acord Forms cannot be accepted as proof)

Disability Insurance (Attach proof of Insurance form to application) Check which form is provided as proof:

Form DB-120.1

Form DB-155

(note: Acord Forms cannot be accepted as proof)

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