"Food Service Application Form" - Decatur County, Indiana

Food Service Application Form is a legal document that was released by the Health Department - Decatur County, Indiana - a government authority operating within Indiana. The form may be used strictly within Decatur County.

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FOOD SERVICE APPLICATION FORM
Decatur County Health Department
801 N. Lincoln Street
Greensburg IN 47240
(812)663-8301 Fax (812)663-4174
Please send this form along with your payment by January 1
, 2019. If you are requesting tax exempt status, please submit a copy of your 501 c 3.
st
Fill out this form as you want it to appear on your permit. An incomplete form will not be processed for a permit. Please enclose a copy of your
NOTE THE NEW FEE SCHEDULE BELOW.
entire menu.
Facility Name (As it will appear on permit)
Phone
Fax
Facility Address:
__
E-mail:
City:
Website:
___________________
Zip Code: _
OWNERSHIP INFORMATION
Ownership Legal Type:
Association
Corporation
Individual
Partnership
Non-Profit
Other________________________
(please include 501c3)
Owner’s Name:
_
Owner’s Phone
Address:
Owner’s Cell Phone
City
Owner’s Email __________________________________
ZIP:
ST:
MANAGEMENT INFORMATION
Person in Charge has the oversight of a zone, district or region.
Name of person in Charge:
Title: ______________________________________
Telephone:
Operator has oversight of the preparation or serving of food at the establishment.
Name of Operator:
Title: ______________________________________
Telephone:
Enclose copies with application
Name(s) of Certified Food Handler(s):
Date of Exam:
MAILING ADDRESS
Please send all future correspondence via email
Address for correspondence, including application or email address if you prefer:
Name
Email Address ______________________________________
Address
City ST:
ZIP
Office Use Only
Establishment #
Menu Type
1
2
3
4
5
The following information is REQUIRED if applicable.
1
FOOD SERVICE APPLICATION FORM
Decatur County Health Department
801 N. Lincoln Street
Greensburg IN 47240
(812)663-8301 Fax (812)663-4174
Please send this form along with your payment by January 1
, 2019. If you are requesting tax exempt status, please submit a copy of your 501 c 3.
st
Fill out this form as you want it to appear on your permit. An incomplete form will not be processed for a permit. Please enclose a copy of your
NOTE THE NEW FEE SCHEDULE BELOW.
entire menu.
Facility Name (As it will appear on permit)
Phone
Fax
Facility Address:
__
E-mail:
City:
Website:
___________________
Zip Code: _
OWNERSHIP INFORMATION
Ownership Legal Type:
Association
Corporation
Individual
Partnership
Non-Profit
Other________________________
(please include 501c3)
Owner’s Name:
_
Owner’s Phone
Address:
Owner’s Cell Phone
City
Owner’s Email __________________________________
ZIP:
ST:
MANAGEMENT INFORMATION
Person in Charge has the oversight of a zone, district or region.
Name of person in Charge:
Title: ______________________________________
Telephone:
Operator has oversight of the preparation or serving of food at the establishment.
Name of Operator:
Title: ______________________________________
Telephone:
Enclose copies with application
Name(s) of Certified Food Handler(s):
Date of Exam:
MAILING ADDRESS
Please send all future correspondence via email
Address for correspondence, including application or email address if you prefer:
Name
Email Address ______________________________________
Address
City ST:
ZIP
Office Use Only
Establishment #
Menu Type
1
2
3
4
5
The following information is REQUIRED if applicable.
1
FOOD SERVICE APPLICATION FORM
Decatur County Health Department
801 N. Lincoln Street
Greensburg IN 47240
(812)663-8301 Fax (812)663-4174
Meals Served (check all that apply)
Breakfast
Lunch
Dinner
Cater
Mobile Unit
Days and Hours of Operation
Day
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Opening
Time
Closing
Time
The Undersigned Hereby applies for a permit to operate a Food Service Establishment pursuant to Decatur County Ordinance 2006-4. The undersigned hereby attests
to the accuracy of the information provided in this application and affirms that the undersigned will comply with the ordinance, and allow the Decatur County Health
Official full access to the establishment.
Signature of Applicant(s):
Printed Name of Applicant(s):
*******************New Fee Schedule********************
Food Service Facility
# Employees
1-9
$200.00
10-20
$300.00
21+
*$600.00
Retail Food Store
Square Footage
1-1000 ft²
$200.00
1001-8000 ft²
$300.00
>8000 ft²
* $600.00
********* Please enclose copies of menus and food handler certifications. *********
Please make check payable to:
Decatur County Health Department
*New Fee for 2019
2
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