Form FSI-463 "Application for Food Salvager License - Article 17-b" - New York

What Is Form FSI-463?

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-463 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-463 "Application for Food Salvager License - Article 17-b" - New York

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FSI-463 (1/17)
APPLICATION FOR FOOD SALVAGER LICENSE – ARTICLE 17-B
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, NY 12235
Office Use Only
County Code- Est. No.
Entity No. ____________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application.
An original signature of owner or corporate officer is
required in Section (6).
Completion and submission of this form does not
constitute authorization to operate as a Food Salvager.
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-Mail:
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).
Title
Work Address (Street & No., City, State, Zip)
Date of
Name (Please Print)
E-Mail address
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-463 (1/17)
APPLICATION FOR FOOD SALVAGER LICENSE – ARTICLE 17-B
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, NY 12235
Office Use Only
County Code- Est. No.
Entity No. ____________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application.
An original signature of owner or corporate officer is
required in Section (6).
Completion and submission of this form does not
constitute authorization to operate as a Food Salvager.
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-Mail:
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).
Title
Work Address (Street & No., City, State, Zip)
Date of
Name (Please Print)
E-Mail address
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-463 (1/17)
(5) Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation
Insurance (WCI). Indicate your WCI status:
Insured with __________________________________________________
Self Insured
Exempt from WCI
Name of Insurance Provider
(6) The undersigned applies for a license to conduct a food salvage business at this location only, pursuant to Article 17-B of the Agriculture and Markets Law of
the State of New York and in support of this application agrees to comply with requirements of Article 17-B and with the rules and regulations promulgated
pursuant thereto.
The applicant represents that there are adequate physical facilities, to conduct a food salvage business at the location for which this license application is made.
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 Commissioner’s duties to supervise and regulate storage, sale and use of articles subject to the Commissioner’s jurisdiction.
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.
Applicant understands the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.
In addition to being a basis for denial or revocation of license, any false statements made herein are punishable pursuant to Section 210.45 of the Penal Law of
the State of New York.
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: Department of Agriculture and Markets; Attn: Food Safety License Unit, 10B Airline Drive, Albany, NY 12235.
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