Form Ehs - New Food Service Establishment Permit Application (Page 2 of 3) in pdf

SECTION D – Complete for SEASONAL FOOD SERVICE* Establishments only

* To qualify as Seasonal, your establishment must be open for business no more than 6 consecutive months per year.

Expected Opening Date: ________________________________

Expected Closing Date: _______________________________

Food to be served: ________________________________________________________________________________________________________

________________________________________________________________________________________________________

A PRESEASONAL INSPECTION IS REQUIRED - PLEASE CALL 737-2019 FOR AN APPOINTMENT

SECTION E - COMPLETE FOR MOBILE FOOD SERVICE UNITS OR PUSHCARTS ONLY

Type of vehicle:

Motorized (License plate #: __________________)

Pushcart

Other:__________________

Commissary address*

(Location

_________________________________________________________________________________

where food is made and/or stored):

Food to be served: ________________________________________________________________________________________________________

A PRESEASONAL INSPECTION IS REQUIRED - PLEASE CALL 737-2019 FOR AN APPOINTMENT

SECTION F - COMPLETE FOR VENDING (FOOD AND BEVERAGE MACHINES) or CATERING

Commissary address*

(Location

______________________________________________________________________________

where food is made and/or stored):

>>> Please attach a list of all vending machine locations and food dispensed at each location.

*Note: If commissary is located outside of Chemung Co. you must attach a copy of your most recent inspection

report by the local Health Department along with a copy of a valid Health Permit for the facility.

SECTION G - CORPORATE OFFICERS OR ORGANIZATION LEADERS

List all corporate officers or organization leaders involved in the operation of the facility. Include vice president(s),

secretary, treasurer, etc. Attach additional sheets as necessary.

Name:

Title:

Home Address:

Home Phone:

_____________________________

_____________________

_____________________________________________

________________

_____________________________

_____________________

_____________________________________________

________________

_____________________________

_____________________

_____________________________________________

________________

_____________________________

_____________________

_____________________________________________

________________

SECTION H – BUILDING OWNER INFORMATION

Regarding the building in which your Food Service Establishment will operate (mark one):

I own the building

I rent/lease the building from ______________________________________

______________________

Contact Phone:

SECTION I - SIGNATURE - - - ENTIRE SECTION MUST BE COMPLETED BY ALL APPLICANTS - - -

FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.

Failure to sign this form will delay issuance of your permit to operate. APPLICATION FEES ARE NON-REFUNDABLE.

I certify that the information provided on this application is true.

SIGNATURE OF OPERATOR: _____________________________________________ Date: ____________________

Print Name: ______________________________________________ Title: ___________________

EHS (rev. 12-8-17)

Form Ehs - New Food Service Establishment Permit Application Page 2

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