Form FSI-351 "Application for Refrigerated Warehouse/Locker Plant/Fresh Fruit and/Or Vegetable Storage Facility License - Article 19" - New York

What Is Form FSI-351?

This is a legal form that was released by the New York State Department of Agriculture and Markets - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the New York State Department of Agriculture and Markets;
  • 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 printable version of Form FSI-351 by clicking the link below or browse more documents and templates provided by the New York State Department of Agriculture and Markets.

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Download Form FSI-351 "Application for Refrigerated Warehouse/Locker Plant/Fresh Fruit and/Or Vegetable Storage Facility License - Article 19" - New York

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FSI-351 (1/17)
APPLICATION FOR REFRIGERATED WAREHOUSE/LOCKER PLANT/
FRESH FRUIT AND/OR VEGETABLE STORAGE FACILITY – ARTICLE 19
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No. _______________________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is
required in Section (11).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number:
OR
Social Security Number:
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Name (Please Print)
Title
Contact Address (Street & No., City, State, Zip), E-Mail address
Date of Birth
(4a.) Principal Office Address: _______________________________________________________________________________________________
(4b.) In what state incorporated? _________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
FSI-351 (1/17)
APPLICATION FOR REFRIGERATED WAREHOUSE/LOCKER PLANT/
FRESH FRUIT AND/OR VEGETABLE STORAGE FACILITY – ARTICLE 19
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No. _______________________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is
required in Section (11).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number:
OR
Social Security Number:
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Name (Please Print)
Title
Contact Address (Street & No., City, State, Zip), E-Mail address
Date of Birth
(4a.) Principal Office Address: _______________________________________________________________________________________________
(4b.) In what state incorporated? _________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
(5) State experience which qualifies the applicant (or its officers, if a corporation) to conduct this business, giving names of firms
previously associated with ________________________________________________________________________________
_____________________________________________________________________________________________________
(6) Does the applicant or an officer, director, partner or any stockholder exercising any position of management or control have any
unsatisfied legal judgements outstanding?
Yes
No If yes, explain and specify the amount _______________________
__________________________________________________________________________________________________________
(7) Has the applicant or an officer, director, partner or any stockholder exercising any position of management or control ever been
adjudged bankrupt?
Yes
No If yes, explain ____________________________________________________________
__________________________________________________________________________________________________________
Note: This license is not required if no space is offered for rent
(8) State rental capacity of refrigerated warehouse and/or locker plant in cubic feet ______________________________________
and temperature to be maintained ______________________________________
(9) State the kind of foods to be stored _______________________________________________________________________
(10)
Facility is used entirely for commercial rental and/or locker storage.
Facility is used for both commercial rental and foods owned by the applicant
Applicant has access to all lockers
Individual lockers are offered for rent.
.
The individual lockers are maintained by the applicant.
(11) ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER TITLE DATE
Applicant represents that there are adequate physical facilities and equipment to maintain adequate sanitation for the activities conducted and that the
establishment will be maintained in a clean and sanitary condition and operated in a sanitary manner and that the maintenance and operation of the
establishment will be such that the product held or stored therein will not be adulterated, and that the premises are operated in accordance with Article
19 of the Agriculture and Markets Law and Part 270 of the regulations.
Applicant consents to free entry and will permit free access to the licensed premises, buildings and offices to the Commissioner, the Commissioner’s
agents and inspectors in pursuance of the Commissioners duties to supervise and regulate the production, storage, sale and use of articles subject to
the Commissioners jurisdiction.
Applicant understands the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.
Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application, may be
punishable under the provisions of Section 210.45 of the Penal Law of the State of New York.
NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that the applicant, licensee, officer,
director, partner or share/stockholder, has been convicted of, or has pled guilty to, a felony in any court of the United States or any State or territory
thereof, with respect to an offense involving; food safety, food adulteration or food misbranding.
Providing your signature below acknowledges your understanding of requirements listed herein and that you agree to comply with the requirements of
Article 19.
SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER
TITLE
DATE
AUTHORIZATION AND PURPOSE
Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York
State Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have
been delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered
by the Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law. The authority to
solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific license you are
seeking. This information is collected to enable the Department to evaluate your application, to determine if it should be issued and to assist in the
enforcement and administration of the Agriculture and Markets Law.
If you have questions about the information requested, call (518) 457-7139; e-mail agr.sm.foodlicense@agriculture.ny.gov; or write to: NYS
Department of Agriculture and Markets; Attn: Food Safety License Unit; 10B Airline Drive; Albany, NY 12235.
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