Create an Account - Increase your productivity, customize your experience, and engage in information you care about.
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:
OPEN - circle one AM/PM
CLOSE - circle one AM/PM
Legal operator or operating corporation (If corporation or partnership, Section F must be completed.)
If no, proceed to Section D
If no, proceed to Section E
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.
Check the appropriate lines and submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law:
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.
Signature of individual operator or authorized official
* indicates a required field