"Food Safety Division License Application Form" - Georgia (United States)

This Georgia-specific "Food Safety Division License Application Form" is a document released by the Georgia Department of Agriculture.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Food Safety Division License Application Form" - Georgia (United States)

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Gary W. Black
GEORGIA DEPARTMENT OF AGRICULTURE - LICENSING DIVISION
COMMISSIONER
19 Martin Luther King Jr Dr SW, Room 604 Atlanta, GA 30334
404.586.1411 (TEL) • 855.424.5423 (TOLL FREE) • 404.586.1126 (FAX)
GDALICENSING@AGR.GEORGIA.GOV
FOOD SAFETY DIVISION LICENSE APPLICATION
GDA:FSDLA:073015
LICENSES SOUGHT
FOOD SALES ESTABLISHMENT
MOBILE VEHICLE
WHOLESALE FISH DEALER
(Check all that apply)
ESTABLISHMENT INFORMATION
Firm Name (Doing Business As)
Water: Public or Well
Water: Sewer or Septic
Corporation Name (As Filed With the Secretary of State)
Ownership: Individual, Partnership, Corporation, LLP, or LLC
PHYSICAL ADDRESS
Street Address
City
County
Zipcode
MAILING ADDRESS
(If Different from PHYSICAL ADDRESS)
Street Address
City
State
Zipcode
PHONE & ADDITIONAL INFORMATION
Phone Number
Fax Number
Contact Number - Owner
Projected Opening Date
Construction: New or Existing
OWNER INFORMATION
Owner or Corporate Officer Name
Title
CO-OWNERS/PARTNERS/CORPORATE OFFICERS
Name
Title
Name
Title
EMAIL ADDRESS
(Valid Email Address Required for License Renewal)
VEHICLE INFORMATION
(For MOBILE VEHICLE, WHOLESALE FISH LICENSE, or ROLLING STORES (FOOD SALES) as applicable)
VIN Number
Tag - Number
Tag - State
Make
Model
Year
WHOLESALE FISH DEALERS*
List all the fishery products your firm plans to wholesale, noting each item as either FRESH or FROZEN. Use the back of the form if you need additional space.
*A HACCP System that complies with state and federal regulations may be required for fishery products your firm produces or distributes.
Please submit HACCP plans/forms to the Seafood Safety Office via FAX: 912-966-7954 or by EMAIL: Tony.Colvin@agr.georgia.gov
LICENSING INFORMATION
Type
Renewal Period
Fees
Verification of Lawful Presence
Food Sales
Fiscal Year
A notarized affidavit and acceptable documentation is required by O.C.G.A. § 50-36-1.
License Fee Based on Risk Tier:
License
(Jul 1 - Jun 30)
$100/$150/$200/$250/$300
Please notify us if you have previously submitted an affidavit and one acceptable
Mobile Vehicle
Annual
document for any other license or GATE card issued by the Department.
$100
License
(Application Date)
This will allow us to search our databases and upload the required documentation for
your
new
license
and
enable
a
better
customer
service
experience.
Wholesale Fish
Calendar Year
$60 Resident ($30 after June 30)
License
(Jan 1 - Dec 30)
Out of State - Call For License Fee
For assistance, call the Customer Service Center at 855-4-AG-LICENSE (855-424-5423).
Make Check or Money Order Payable To: GEORGIA DEPARTMENT OF AGRICULTURE
APPLICANT - PRINTED NAME
APPLICANT - TITLE
APPLICANT - SIGNATURE
APPLICATION DATE
DEPARTMENT USE ONLY
Sanit. ID #
FTC
Date Received
Check Date
Check Number
Amount Paid
License #
Gary W. Black
GEORGIA DEPARTMENT OF AGRICULTURE - LICENSING DIVISION
COMMISSIONER
19 Martin Luther King Jr Dr SW, Room 604 Atlanta, GA 30334
404.586.1411 (TEL) • 855.424.5423 (TOLL FREE) • 404.586.1126 (FAX)
GDALICENSING@AGR.GEORGIA.GOV
FOOD SAFETY DIVISION LICENSE APPLICATION
GDA:FSDLA:073015
LICENSES SOUGHT
FOOD SALES ESTABLISHMENT
MOBILE VEHICLE
WHOLESALE FISH DEALER
(Check all that apply)
ESTABLISHMENT INFORMATION
Firm Name (Doing Business As)
Water: Public or Well
Water: Sewer or Septic
Corporation Name (As Filed With the Secretary of State)
Ownership: Individual, Partnership, Corporation, LLP, or LLC
PHYSICAL ADDRESS
Street Address
City
County
Zipcode
MAILING ADDRESS
(If Different from PHYSICAL ADDRESS)
Street Address
City
State
Zipcode
PHONE & ADDITIONAL INFORMATION
Phone Number
Fax Number
Contact Number - Owner
Projected Opening Date
Construction: New or Existing
OWNER INFORMATION
Owner or Corporate Officer Name
Title
CO-OWNERS/PARTNERS/CORPORATE OFFICERS
Name
Title
Name
Title
EMAIL ADDRESS
(Valid Email Address Required for License Renewal)
VEHICLE INFORMATION
(For MOBILE VEHICLE, WHOLESALE FISH LICENSE, or ROLLING STORES (FOOD SALES) as applicable)
VIN Number
Tag - Number
Tag - State
Make
Model
Year
WHOLESALE FISH DEALERS*
List all the fishery products your firm plans to wholesale, noting each item as either FRESH or FROZEN. Use the back of the form if you need additional space.
*A HACCP System that complies with state and federal regulations may be required for fishery products your firm produces or distributes.
Please submit HACCP plans/forms to the Seafood Safety Office via FAX: 912-966-7954 or by EMAIL: Tony.Colvin@agr.georgia.gov
LICENSING INFORMATION
Type
Renewal Period
Fees
Verification of Lawful Presence
Food Sales
Fiscal Year
A notarized affidavit and acceptable documentation is required by O.C.G.A. § 50-36-1.
License Fee Based on Risk Tier:
License
(Jul 1 - Jun 30)
$100/$150/$200/$250/$300
Please notify us if you have previously submitted an affidavit and one acceptable
Mobile Vehicle
Annual
document for any other license or GATE card issued by the Department.
$100
License
(Application Date)
This will allow us to search our databases and upload the required documentation for
your
new
license
and
enable
a
better
customer
service
experience.
Wholesale Fish
Calendar Year
$60 Resident ($30 after June 30)
License
(Jan 1 - Dec 30)
Out of State - Call For License Fee
For assistance, call the Customer Service Center at 855-4-AG-LICENSE (855-424-5423).
Make Check or Money Order Payable To: GEORGIA DEPARTMENT OF AGRICULTURE
APPLICANT - PRINTED NAME
APPLICANT - TITLE
APPLICANT - SIGNATURE
APPLICATION DATE
DEPARTMENT USE ONLY
Sanit. ID #
FTC
Date Received
Check Date
Check Number
Amount Paid
License #
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