Form Ehs - New Food Service Establishment Permit Application Page 3
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3INSTRUCTIONS FOR FILLING OUT ATTACHED APPLICATION
Please review the information on the attached application. Some of the information is already filled in for you.
If any information is incorrect please annotate changes and fill in all other blank areas that apply (such as hours of
operation). Please note the following:
APPLICATION FEES ARE NON-REFUNDABLE
Make Checks payable to: Chemung County Health Department.
Please provide us with your e-mail address. Inspection reports will now be electronic and have to be
emailed to the facility operator. This information is for our use only and will not be shared.
WORKERS' COMPENSATION AND DISABILITY INSURANCE
As a government agency we are prohibited from issuing permits until you submit either proof of insurance or a
CE-200 Exemption form. See below for details.
SIGNATURE - All applications must be signed (on back).
Workers' Compensation and Disability Insurance Requirements
for Permitted Facilities
The following forms are required to document compliance with the Worker’s Compensation Law. Permits will not
be issued without this paperwork. These forms can be faxed to our office at (607) 737-2059, emailed to
EHS@co.chemung.ny.us
or mailed to our office along with your application.
When Worker’s Comp and/or Disability coverage IS provided.
Proof of Workers' Compensation Insurance:
Form C-105.2 – Certificate of Worker's Compensation Insurance (Contact your Insurance carrier; they will
have to generate this form).
Note:
Form C-105 is not acceptable proof, must be form C-105.2
OR
Form U-26.3 – Certificate of Workers' Compensation Insurance (Issued by the State Insurance Fund, you
One
of
will have to contact them.
OR
these
Form SI-12 – Certificate of Workers' Comp Self-Insurance
(usually only applies to major corporations or government agencies).
OR
GSI – 105.2
–
Certificate of Participation in Workers' Compensation Group Self-Insurance
(usually only applies to major
corporations or government agencies).
AND
Proof of Disability Benefits Insurance:
DB-120.1 - Certificate of Disability Benefits (Contact your Insurance carrier, they will have to generate this
One
form).
Note:
Form DB-120 is not acceptable proof, must be form DB-120.1
of
OR
these
Form DB-155 – Certificate of Disability Benefits Self-Insurance Insurance
(usually only applies to major corporations or government
agencies).
Important: Acord Forms are not acceptable as proof of WC/DB insurance coverage.
When Worker’s Comp and/or Disability coverage IS NOT provided.
Form CE-200 – Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability
Benefits Coverage.
You can obtain form CE-200 from one of the following:
On-line -
There is a direct link to the Exemption Form (CE-200) on our website
near the
bottom of the main page.
(Note: You will need to turn off Pop-up Blockers on your computer in order to print form).
Worker’s Compensation Office at 167 Lake St., Elmira, NY.
Submit the completed and signed CE-200 to our office along with your application.
EHS (rev. 12-8-17)
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