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: _________________________________________
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?
No
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
No
(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)
OR -- >
Form CE-200 submitted to this Department on: ____________
(This exemption form need only be filled out if you do not have insurance listed above)
Note: You must attach a copy of your completed form CE-200 to this application, please be sure to sign the bottom of this form.
EHS (rev. 12-8-17)