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Application for a Permit to Operate

  1. Complete all items that apply to your establishment (all applicants must complete Sections A, B, G and H), sign on the back page and return with the appropriate fee at least 30 days prior to the expected opening date to:

  2. ENVIRO-HLTH-ADDR.JPG

  3. Indicate days operation is open*

  4. Facility Status*

  5. OPEN - circle one AM/PM

  6. CLOSE - circle one AM/PM

  7. Number of operations under this registration - check all that apply*

  8. Water Suppy*

  9. Sewage System*

  10. Legal operator or operating corporation (If corporation or partnership, Section F must be completed.)

  11. Are you a temporary food service establishment*

    If no, proceed to Section D

  12. Are you a mobile food service establishment?*

    If no, proceed to Section E

  13. Type of vehicle

  14. List all partners and corporate officers in the operation of the facility. Include vice president(s), secretary, treasurer. Attach DOH-2135 (or additional sheets) as necessary.

  15. Check the appropriate lines and submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law:

  16. A. Workers Compensation PROVIDED

  17. AND Disability Insurance PROVIDED

  18. B. Workers Compensation and Disability Insurance NOT PROVIDED

  19. Do you have an employee certified in food safety?*

  20. FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. Failure to provide Employee Identification or SSN and sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code.

  21. Signature of individual operator or authorized official

  22. Permit issuance recommended?

  23. Leave This Blank: