"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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Food Safety Section – Room 220
1445 Federal Drive ● Montgomery, Alabama 36107-1123
Phone 334-240-7202 ● 1-800-642-7761, Ext. 7202
Rick Pate
Commissioner
APPLICATION FOR FOOD SAFETY PERMIT - $50
1, 2020
30, 2021
FOR PERIOD JULY
– JUNE
**DO NOT SEND CASH** WE ACCEPT CHECK OR MONEY ORDER ONLY
Make Payable to: Alabama Department of Agriculture / Food Safety Section.
Date: ____________________________
Renewal
New Store
Store I.D. _________________________
(See Renewal Letter)
Change of store name
Store Type: ________________________
Change of owner
(i.e. grocery market, convenience store, etc.)
The undersigned hereby makes application for Food Safety Permit as required by the “Alabama Safe Foods Act of 2000”, Chapter 1, Title 20, Code of
Alabama (1975) (20-1-33 ; 80-1-22-.32) 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.).
STORE NAME _________________________________________________________________________
PHSYICAL ADDRESS ____________________________________________
(
)_________________
PHONE NUMBER
CITY, STATE, ZIP _______________________________________________
____________________
COUNTY
EMAIL ADDRESS _____________________________________________________________________
MAILING SAME AS PHSYICAL
MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL) ___________________________________________
ATTN TO ___________________________________
_______________________________________
)
(CITY, STATE, ZIP
PHONE NUMBER (
) _______________________
*If application is postmarked after July 31st 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 ______________________________
***DO NOT WRITE IN THIS BOX - FOR FOOD SAFETY OFFICE USE ONLY***
Money Order / Check # _____________________
Check Amount $________________
Date Processed ____________________________
Approved by ___________________
PERMIT NUMBER ________________________
TOTAL $_______________________
Food Safety Section – Room 220
1445 Federal Drive ● Montgomery, Alabama 36107-1123
Phone 334-240-7202 ● 1-800-642-7761, Ext. 7202
Rick Pate
Commissioner
APPLICATION FOR FOOD SAFETY PERMIT - $50
1, 2020
30, 2021
FOR PERIOD JULY
– JUNE
**DO NOT SEND CASH** WE ACCEPT CHECK OR MONEY ORDER ONLY
Make Payable to: Alabama Department of Agriculture / Food Safety Section.
Date: ____________________________
Renewal
New Store
Store I.D. _________________________
(See Renewal Letter)
Change of store name
Store Type: ________________________
Change of owner
(i.e. grocery market, convenience store, etc.)
The undersigned hereby makes application for Food Safety Permit as required by the “Alabama Safe Foods Act of 2000”, Chapter 1, Title 20, Code of
Alabama (1975) (20-1-33 ; 80-1-22-.32) 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.).
STORE NAME _________________________________________________________________________
PHSYICAL ADDRESS ____________________________________________
(
)_________________
PHONE NUMBER
CITY, STATE, ZIP _______________________________________________
____________________
COUNTY
EMAIL ADDRESS _____________________________________________________________________
MAILING SAME AS PHSYICAL
MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL) ___________________________________________
ATTN TO ___________________________________
_______________________________________
)
(CITY, STATE, ZIP
PHONE NUMBER (
) _______________________
*If application is postmarked after July 31st 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 ______________________________
***DO NOT WRITE IN THIS BOX - FOR FOOD SAFETY OFFICE USE ONLY***
Money Order / Check # _____________________
Check Amount $________________
Date Processed ____________________________
Approved by ___________________
PERMIT NUMBER ________________________
TOTAL $_______________________