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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. SECTION A: Facility Information (Entire section must be completed by all applicants.)

  4. Indicate days operation is open*

  5. Facility Status*

  6. OPEN - circle one AM/PM

  7. CLOSE - circle one AM/PM

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

  9. Water Suppy*

  10. Sewage System*

  11. SECTION B: Operator/Owner Information (Entire section must be completed by all applicants.)

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

  12. SECTION C: Complete for temporary food service establishments only (attach additional sheets as necessary).

  13. Are you a temporary food service establishment*

    If no, proceed to Section D

  14. SECTION D: Complete for mobile food service establishments or pushcarts only.

  15. Are you a mobile food service establishment?*

    If no, proceed to Section E

  16. Type of vehicle

  17. SECTION E: Food and beverage machines only. Attach a list of all machine locations and food dispensed.

  18. SECTION F: Partners and Corporate Officers

    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.

  19. SECTION G: Workers' Compensation and Disability Insurance (All applicants must complete this section.)

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

  20. A. Workers Compensation PROVIDED

  21. AND Disability Insurance PROVIDED

  22. B. Workers Compensation and Disability Insurance NOT PROVIDED

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

  24. SECTION H: Signature (Entire section must be completed by all applicants.)

    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.

  25. **REQUIRED** Employee Identification Number or SSN ______________________________________

  26. **REQUIRED** Signature __________________________________________________________________

    Signature of individual operator or authorized official

  27. SECTION I: FOR OFFICE USE ONLY

  28. Permit issuance recommended?

  29. Signature________________________________________Title____________________Date______________

  30. 3/2014

  31. Leave This Blank: