Form ACDOH-101 "Application for a Permit to Operate" - Allegany County, New York

Form ACDOH-101 Printable Pdf
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What Is Form ACDOH-101?

This is a legal form that was released by the Department of Health - Allegany County, New York - a government authority operating within New York. The form may be used strictly within Allegany County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Department of Health - Allegany County, New York;
  • 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 fillable version of Form ACDOH-101 by clicking the link below or browse more documents and templates provided by the Department of Health - Allegany County, New York.

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Download Form ACDOH-101 "Application for a Permit to Operate" - Allegany County, New York

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Application for a Permit to Operate
Allegany County Department of Health
7 Court Street, Belmont, New York 14813
A. Facility Information (Entire section must be completed by all applicants.)
Facility __________________________________________________________ Phone________________
Address__________________________________________________________
____________________________________________________________
Location (Town/Village)________________________________________ County Allegany
B. Operations Regulated by this Permit
□
□
□
Permitted Operation(s):
Food Service
Bathing Beaches
Campgrounds
□
□
□
Frozen Dessert
Indoor Pool
Day Camp
□
□
Mobile Food Service
Other: ___________________
Fee Exempt _____________
Total Fee Due $_____________
□
□
□
Capacity________________
Units:
Seats
Rooms/Units
Persons
□
□
□
Sites
Swimmers
Beds
□
□
□
In Operation:
Year-Round
Seasonal
Temporary
□
□
□
□
Expected
Expected
Days of
Sun
Mon
Tues
Wed
□
□
□
□
Opening date ________
Closing date _________
Operation:
Thur
Fri
Sat
Sun
Hours of Operation ____________ am / pm TO ____________ am / pm
□
□
Water Supply:
Public (municipal)
Private (onsite)
□
□
Sewage System:
Public (municipal)
Private (onsite)
C. Operator / Owner Information
(Check all that apply)
□
□
□
Receives Application
Receives Mail
Responsible Person
Legal Operator or operating corporation ______________________________________________
(If corporation or partnership, Section G must be completed.)
Title ________________________
Person in Charge _____________________________________________ Phone ______________
Address__________________________________________________________
___________________________________________________________
E-Mail ______________________________________________________
Employer Identification Number ____-__________ OR Social Security Number ____-____-_____
Owner ______________________________________________________
Permanent Address___________________________________________
____________________________________________ Phone _____________
Alternate Address ___________________________________________
____________________________________________ Phone _____________
From: _____________________ To: ________________________
Application for a Permit to Operate
Allegany County Department of Health
7 Court Street, Belmont, New York 14813
A. Facility Information (Entire section must be completed by all applicants.)
Facility __________________________________________________________ Phone________________
Address__________________________________________________________
____________________________________________________________
Location (Town/Village)________________________________________ County Allegany
B. Operations Regulated by this Permit
□
□
□
Permitted Operation(s):
Food Service
Bathing Beaches
Campgrounds
□
□
□
Frozen Dessert
Indoor Pool
Day Camp
□
□
Mobile Food Service
Other: ___________________
Fee Exempt _____________
Total Fee Due $_____________
□
□
□
Capacity________________
Units:
Seats
Rooms/Units
Persons
□
□
□
Sites
Swimmers
Beds
□
□
□
In Operation:
Year-Round
Seasonal
Temporary
□
□
□
□
Expected
Expected
Days of
Sun
Mon
Tues
Wed
□
□
□
□
Opening date ________
Closing date _________
Operation:
Thur
Fri
Sat
Sun
Hours of Operation ____________ am / pm TO ____________ am / pm
□
□
Water Supply:
Public (municipal)
Private (onsite)
□
□
Sewage System:
Public (municipal)
Private (onsite)
C. Operator / Owner Information
(Check all that apply)
□
□
□
Receives Application
Receives Mail
Responsible Person
Legal Operator or operating corporation ______________________________________________
(If corporation or partnership, Section G must be completed.)
Title ________________________
Person in Charge _____________________________________________ Phone ______________
Address__________________________________________________________
___________________________________________________________
E-Mail ______________________________________________________
Employer Identification Number ____-__________ OR Social Security Number ____-____-_____
Owner ______________________________________________________
Permanent Address___________________________________________
____________________________________________ Phone _____________
Alternate Address ___________________________________________
____________________________________________ Phone _____________
From: _____________________ To: ________________________
D. Complete for temporary food service establishments only (attach additional paper if needed)
Name of location of event _________________________________________________________________
Name of Food
Supplier of ingredients
Where and how foods will be prepared and served
E. Complete for mobile food service establishments or pushcarts only.
□
□
□
Type of Vehicle:
Motorized
Pushcart
Other (specify) ________________
Motor vehicle license no. (for motorized vehicles) _____________________
Commissary name ___________________________________________ Phone ______________
Address__________________________________________________________
___________________________________________________________
List on separate sheet types of food and beverages served.
F. Food and beverage machines only. Attach a list of all machine locations and food dispensed.
G. Partners and Corporate Officers
List all partners and cooperate officers in the operation of the facility. Include vice president(s), secretary, and
treasurer. Attach DOH-2135 (or additional sheets) as necessary.
Name
Title
Address
Phone
H. Workers’ Compensation and Disability Insurance (All applicants must complete this section.)
When WC/DB coverage IS provided.
Workers’ Compensation:
Form C-105.2 – Certificate of Worker’s Compensation Insurance (issued by the applicant’s insurance carrier);
o
OR
Form U-26.3 – Certificate of Workers’ Compensation Insurance (issued by the State Insurance Fund); OR
o
Form SI-12 – Certificate of Workers’ Compensation Self-Insurance, at 518-402-0247 OR
o
GSI-105.2 – Certificate of Participation in Workers’ Compensation Group Self-Insurance; AND
o
Disability Benefits:
DB-120.1 – Certificate of Disability Benefits (issued by the applicant’s insurance carrier); OR
o
Form DB-155 – Certificate of Disability Benefits Self-Insurance
o
When WC/DB coverage IS NOT provided.
Form CE-200 – Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits
Coverage
To obtain an exemption of WC/DI please visit:
http://www.wcb.state.ny.us
I. Signature
FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW
Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a
violation of the State Sanitary Code.
Signature of individual operator or authorized official _________________________________________
Print name of person signing ___________________________________________ Title ______________
ACDOH-101 (01/11)
Department of Health - Allegany County, New York New York Legal Forms United States Legal Forms

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