"Application for Food Safety Permit" - Alabama

Application for Food Safety Permit is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

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Download "Application for Food Safety Permit" - Alabama

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Alabama Department of Agriculture and Industries
APPLICATION FOR FOOD SAFETY PERMIT
FOR PERIOD JULY 1, 2018 THROUGH JUNE 30, 2019
$50.00 PERMIT FEE
*$7.50 LATE PENALTY
RETURN COMPLETED & SIGNED FORM WITH PAYMENT TO:
AL Department of Agriculture and Industries
Date _______________________
FOOD SAFETY SECTION – ROOM 218
1445 Federal Drive, Montgomery, AL 36107-1123
PHONE (334) 240-7202
Store I.D. ___________________
Email:
Belinda.mulder@agi.alabama.gov
(See
Renewal Letter)
(QUESTIONS ONLY- DO NOT SEND APPLICATIONS BY EMAIL)
The undersigned hereby makes application for Food Safe Permit as required by the “Alabama Safe Foods Act of 2000”,
Chapter 1, Title 20, Code of Alabama (1975) as amended. A permit fee of $ 50.00 is required for operation of each Food
Sales Establishment that sells baby food, infant formula or potentially hazardous foods (i.e. dairy, eggs, meat, etc.).
PLEASE PRINT LEGIBLY OR TYPE ****
****
BUSINESS NAME
__________________________________________
(
) __________________
PHONE
STREET ADDRESS __________________________________________
CITY, STATE, ZIP
__________________________________________
_________________________
COUNTY
EMAIL ADDRESS
__________________________________________
MAIL PERMIT TO –
__________________________________
(
_)_________________
NAME
(Business Name or Individual’s Name)
PHONE
_____________________________________________________
________________________________
MAILING ADDRESS
CITY, STATE, ZIP
st
*If application is postmarked after July 31
you must include the 15% PENALTY of $7.50 for a
PERMIT TOTAL of $57.50 for each business location.
Application must be signed. In filing this application for a permit, the undersigned agrees to comply with the Alabama
Safe Foods Act and all rules and regulations promulgated thereunder.
SIGNATURE ______________________________________________
PRINT NAME___________________________________
TITLE _________________________________________
Who can we call if we have questions about the info given on this form?
**VERY IMPORTANT:
NAME ____________________________________________________
PHONE (_____)_________________________________
**DO NOT SEND CASH** – WE ACCEPT CHECK OR MONEY ORDER ONLY
Make Payable to: Alabama Department of Agriculture / Food Safety Section.
DO NOT WRITE BELOW THIS LINE. THANK YOU!
*** FOR OFFICE USE ONLY ***
Money Order #_______________________________
CK Amount $________ CK#_____________
Date Processed ______________________________
Permit Fee ________$50________________
Approved By _______________________________
15 % Penalty* ________________________
PERMIT NUMBER _________________________
TOTAL $ ___________________________
Alabama Department of Agriculture and Industries
APPLICATION FOR FOOD SAFETY PERMIT
FOR PERIOD JULY 1, 2018 THROUGH JUNE 30, 2019
$50.00 PERMIT FEE
*$7.50 LATE PENALTY
RETURN COMPLETED & SIGNED FORM WITH PAYMENT TO:
AL Department of Agriculture and Industries
Date _______________________
FOOD SAFETY SECTION – ROOM 218
1445 Federal Drive, Montgomery, AL 36107-1123
PHONE (334) 240-7202
Store I.D. ___________________
Email:
Belinda.mulder@agi.alabama.gov
(See
Renewal Letter)
(QUESTIONS ONLY- DO NOT SEND APPLICATIONS BY EMAIL)
The undersigned hereby makes application for Food Safe Permit as required by the “Alabama Safe Foods Act of 2000”,
Chapter 1, Title 20, Code of Alabama (1975) as amended. A permit fee of $ 50.00 is required for operation of each Food
Sales Establishment that sells baby food, infant formula or potentially hazardous foods (i.e. dairy, eggs, meat, etc.).
PLEASE PRINT LEGIBLY OR TYPE ****
****
BUSINESS NAME
__________________________________________
(
) __________________
PHONE
STREET ADDRESS __________________________________________
CITY, STATE, ZIP
__________________________________________
_________________________
COUNTY
EMAIL ADDRESS
__________________________________________
MAIL PERMIT TO –
__________________________________
(
_)_________________
NAME
(Business Name or Individual’s Name)
PHONE
_____________________________________________________
________________________________
MAILING ADDRESS
CITY, STATE, ZIP
st
*If application is postmarked after July 31
you must include the 15% PENALTY of $7.50 for a
PERMIT TOTAL of $57.50 for each business location.
Application must be signed. In filing this application for a permit, the undersigned agrees to comply with the Alabama
Safe Foods Act and all rules and regulations promulgated thereunder.
SIGNATURE ______________________________________________
PRINT NAME___________________________________
TITLE _________________________________________
Who can we call if we have questions about the info given on this form?
**VERY IMPORTANT:
NAME ____________________________________________________
PHONE (_____)_________________________________
**DO NOT SEND CASH** – WE ACCEPT CHECK OR MONEY ORDER ONLY
Make Payable to: Alabama Department of Agriculture / Food Safety Section.
DO NOT WRITE BELOW THIS LINE. THANK YOU!
*** FOR OFFICE USE ONLY ***
Money Order #_______________________________
CK Amount $________ CK#_____________
Date Processed ______________________________
Permit Fee ________$50________________
Approved By _______________________________
15 % Penalty* ________________________
PERMIT NUMBER _________________________
TOTAL $ ___________________________