Food Establishment Permit Application

1. Name of Establishment

2. Cell Phone

3. Alt. Phone

4. Mailing Address

5. Location of Establishment

6. City

7. State

8. Zip

9. Type of Establishment*

   Select one.

   1. Restaurant
   2. Grocery Store
   3. Nursing Home

   1. Convenience Store
   2. Bar

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

11. Owner's Last Name

12. Owner's Address

13. Owner's Phone*

14. Manager of Establishment*

15. Manager's Address

16. Manager's Phone Number*

17. Type of Ownership*

    Check one

    1. Individual

    1. Partnership

    1. Corporation
18. 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.

19. Signature*

20. Title

21. Date

22. FOR OFFICE USE ONLY

23. Permit Fee:

24. Date Issued:

25. Permit Number:

26. Category:

Leave This Blank:


27. 1. Receive email copy
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field