Looking for a New York State Legal Forms And Templates? Download it for free!

Monroe County Department of Public

DO NOT WRITE IN THIS SPACE Date ___/___/___

Health

Rec. #_________ Check #______ Amount__________

New 

Name/Operator Change 

Food Protection – Room 1020

#________________________Inspector __________

111 Westfall Road

Former Est. Name_____________________________

Rochester, New York 14620

Phone (585) 753-5064 / Fax (585) 753-5013

**** Walk-in Office Hours: M-F 9AM-Noon – Appointment required after Noon and before 4:00PM****

Former Est. Name ______________________________

#___________________________ Inspector_________

APPLICATION FOR A PERMIT TO OPERATE A FOOD SERVICE ESTABLISHMENT

Please complete this form. Print or type all information.

Pursuant to part 14-1.190(c) of the New York State Sanitary Code, I / We hereby submit the following information and make application to operate a food service establishment.

Name of

Number of seats________

Establishment_________________________________________________________________________________________________________

Address______________________________________________________________________________________________________________

Location: _____________________________________________________________ Zip_________ Business Telephone_________________

(city, town or village)

(state)

OWNER/CORPORATION NAME

_________________________________________________________________________________________________________________

(Partnership or Corporate Title – if applicable- copy of certificate attached)

Billing Address _______________________________________City________________________ State______ Zip__________

Home Address (Non PO Box)________________________________________

Home telephone _________________________

Cell Phone___________________________________

E-Mail ________________________________________

Partners’ or Corporate Officers’ Names & Titles

Home Addresses and Phone Number

___________________________________________________

_______________________________________________

___________________________________________________

_______________________________________________

Type of establishment  Restaurant and/or Tavern  Catering  School or College  Retail Bakery  Delicatessen

 Industrial Food Service  Commissary  Mobile Vending (provide details on back)  Pushcart (provide details on back)

Operating Days and Hours ______________________________________________________________________________________

Certified Food Worker (If you do NOT meet the training requirements at time of submission of this application you MUST list the

SCHEDULED training dates & the training providers for these workers and MUST submit proof of completion of course to office)

Name of L1 worker*________________________________________________________Certification # ________________exp___

* Please attach a copy of certificate. (ServSafe, National Registry, or Prometric)

Name of L2 worker**

Certification #

exp

______________________________________________________

________________

___

** Please attach a copy of Level 2 certificate.

Signed___________________________________________________________Date of application

____________________________

Print name _____________________________________________________

Fees:

Bakeries, Commissary, Mobile Units, Pushcarts, Delicatessens & Caterers $225.00

Restaurant Seating 0-25

$170.00

Restaurant Seating 26-50 $230.00

Restaurant Seating 51+

$370.00

(OVER- CONTINUED ON BACK OF PAGE)

Page 1 of 2

Application For A Permit To Operate A Food Service Establishment Form - Monroe County Department Of Public Health

Related Articles

Related forms

Related Categories