Form EHP-99 "Retail Food Establishment Permit Application" - Arkansas

What Is Form EHP-99?

This is a legal form that was released by the Arkansas Department of Health - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Arkansas Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form EHP-99 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Health.

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Download Form EHP-99 "Retail Food Establishment Permit Application" - Arkansas

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ARKANSAS DEPARTMENT OF HEALTH
4815 W. Markham St., Slot 46
Little Rock, AR 72205
Retail Food Establishment Permit Application
THIS APPLICATION TO BE COMPLETED BY THE OPERATOR AND SUBMITTED, WITH APPROPRIATE FEES, TO
THE REGULATORY AUTHORITY 30 DAYS PRIOR TO OPENING
(Please Print Clearly or Type to ensure no delays in processing)
Date:
Name of Establishment:
Check One:
New
Remodel
Mobile Unit / Push Cart
New Ownership of Existing Facility
Incubator / Contract Operator of Existing Facility
If your business is a retail food facility/operation please answer the following questions
Have you been through Retail Food Plan Review? Yes or No
Date?
Have you contacted the Local County Health Department? :
Establishment Information:
911/ PhysicalAddress:
Zipcode:
State:
City:
County:
Telephone:
Name of Owner(s)/Corporation:
Contact Person:
Drivers License # or Gov. ID #
:
Email:
Telephone #
(Please provide the following billing address ONLY if it is different than 911/physical address)
Mailing/Billing Address:
State:
Zip Code:
City:
Municipal Water
Other
Well
Establishment's Water Source:
(please list type)
Establishment's Sewage Disposal:
Septic System
Municipal Sewage
Category:
Check All That Apply:
Restaurant $35.00
Daycare $35.00
Food Store $35.00
Retail Deli/Bakery $35.00
Total Due: $
Kiosk $35.00
Food Mobile $35.00 Food
Private School $35.00
Salvage Permit $35.00
Public School or Charter School $0
Summer Feeding / Afterschool $35.00
1
Private Contractor (Schools) $35.00
EHP-99 (R7/18)
ARKANSAS DEPARTMENT OF HEALTH
4815 W. Markham St., Slot 46
Little Rock, AR 72205
Retail Food Establishment Permit Application
THIS APPLICATION TO BE COMPLETED BY THE OPERATOR AND SUBMITTED, WITH APPROPRIATE FEES, TO
THE REGULATORY AUTHORITY 30 DAYS PRIOR TO OPENING
(Please Print Clearly or Type to ensure no delays in processing)
Date:
Name of Establishment:
Check One:
New
Remodel
Mobile Unit / Push Cart
New Ownership of Existing Facility
Incubator / Contract Operator of Existing Facility
If your business is a retail food facility/operation please answer the following questions
Have you been through Retail Food Plan Review? Yes or No
Date?
Have you contacted the Local County Health Department? :
Establishment Information:
911/ PhysicalAddress:
Zipcode:
State:
City:
County:
Telephone:
Name of Owner(s)/Corporation:
Contact Person:
Drivers License # or Gov. ID #
:
Email:
Telephone #
(Please provide the following billing address ONLY if it is different than 911/physical address)
Mailing/Billing Address:
State:
Zip Code:
City:
Municipal Water
Other
Well
Establishment's Water Source:
(please list type)
Establishment's Sewage Disposal:
Septic System
Municipal Sewage
Category:
Check All That Apply:
Restaurant $35.00
Daycare $35.00
Food Store $35.00
Retail Deli/Bakery $35.00
Total Due: $
Kiosk $35.00
Food Mobile $35.00 Food
Private School $35.00
Salvage Permit $35.00
Public School or Charter School $0
Summer Feeding / Afterschool $35.00
1
Private Contractor (Schools) $35.00
EHP-99 (R7/18)
Food Safety Questions:
1.
Will the facility be serving food to a highly susceptible population?
Yes
No
(young children, the elderly, or the chronically ill)
2.
Will you be using specialized processing methods methods to
preserve, extend shelf life, or render food so that it no longer requires
temperature control for safety such as vacuum packaging, curing,
Yes
No
canning, or pickling? Or sprouting seeds or beans?
a. If yes, do you have a HACCP plan?
Yes
No
3. Is there a policy to exclude or restrict food workers who are sick
Yes
No
or have infected cuts and lesions?
4. Are your managers/workers required to complete food safety training?
Yes
No
DISCLAIMER: A person may not operate a Food Establishment without a valid Permit issued by the
Arkansas Department of Health (ADH). I understand that I must contact the appropriate ADH
representative to schedule a pre-opening inspection. Once the pre-opening inspection is conducted, and
the inspection is satisfactory, a permit will be issued. The permit must be displayed at the food
establishment in a location that is conspicuous to consumers. This permit shall remain valid until
expired, suspended, cancelled, revoked, or unpaid. An annual fee will be billed and due upon receipt.
Permits are not transferable to new owners or new locations. ALL FEES ARE NON-REFUNDABLE.
STATEMENT: I hereby certify that the above information is correct, and I fully understand that any
deviation from the above without prior permission from this Health Regulatory Office may nullify final
approval.
Signature(s)
owner(s) or responsible representative(s)
Date
THIS APPLICATION TO BE COMPLETED BY THE OPERATOR AND SUBMITTED, WITH
APPROPRIATE FEES, TO THE REGULATORY AUTHORITY 30 DAYS PRIOR TO OPENING
Submit to:
Arkansas Department of Health
Food Protection Services
4815 W. Markham St., Slot 46
Little Rock, AR 72205
2
EHP-99 (R 7/18)
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