Food Establishment Permit Application

2. Name of Establishment

3. Cell Phone

4. Alt. Phone

6. Mailing Address

7. Location of Establishment

9. City

10. State

11. Zip

13. Type of Establishment*

    Select one.

    1. Restaurant
    2. Grocery Store
    3. Nursing Home

    1. Convenience Store
    2. Bar

    1. Child Care
    2. Other
15. Owner's First Name

16. Owner's Last Name

18. Owner's Address

20. Owner's Phone*

21. Manager of Establishment*

22. Manager's Address

23. Manager's Phone Number*

25. Type of Ownership*

    Check one

    1. Individual

    1. Partnership

    1. Corporation
27. Permit Agreement Statement
    In consideration of issuance of this permit I understand and agree to familiarize myself and comply with all laws and ordinances applicable to operation of said business and further agree to permit unrestricted access to an authorized representative of the Environmental Services – Food Safety Division for the purpose of conducting inspections necessary to verify with applicable regulations. I understand that by typing my name I am signing this legal document.

    In consideration of issuance of this permit I understand and agree to familiarize myself and comply with all laws and ordinances applicable to operation of said business and further agree to permit unrestricted access to an authorized representative of the Environmental Services – Food Safety Division for the purpose of conducting inspections necessary to verify with applicable regulations. I understand that by typing my name I am signing this legal document.

29. Signature*

30. Title

31. Date

33. FOR OFFICE USE ONLY

35. Permit Fee:

36. Date Issued:

38. Permit Number:

39. Category:

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field