Florida Department of Agriculture and Consumer Services Initial Inspection and Food Permit Application by PermitDocsPrivate


									                                       Florida Department of Agriculture and Consumer Services
                                                       Division of Food Safety               Bureau of Food and Meat Inspection
                                                                                                                        Attention: Records Section
                                                REQUEST FOR INITIAL INSPECTION AND                                    3125 Conner Boulevard C-26
                                                    FOOD PERMIT APPLICATION                                            Tallahassee, FL 32399-1650
                          Select the hand tool and then
  COMMISSIONER            tab thru and fill out the form.         F.S. Chapter 500
                                                                 F.S. Chapter500
                          Check boxes with the mouse.              (850) 488-3951
                                                                 (850) 245-5520
                          Print when filled out.
The Department of Agriculture and Consumer Services is the exclusive regulatory and permitting authority for any person, business or
corporation engaged in manufacturing, processing, packing, holding or preparing food or selling food at wholesale or retail. For purposes
of this application, food is considered to include, but is not limited to, all prepackaged grocery items, prepared foods, packaged ice, bottled
or vended water, candy and other snack foods, soda, infant formula, vitamin and mineral dietary supplements.

                                         INFORMATION ABOUT THE LOCATION TO BE PERMITTED

  ( ) New Business

  Business Name                                                                                                 County
  Business Type             Brief description of the type of business: (ex: retail bakery, convenience store, warehouse, etc.)

  Location Address
  Phone Number                                    Ext.

                       If you manufacture and/or package ice for sale, or if you bottle water for sale, you must also submit with your
                       application. 1. Source(s) of water used. 2. Any treatment provided to the ice prior to packaging.

                                                         INFORMATION ABOUT THE OWNER

  Name of Owner

  Business Type             ( ) Corporation ( ) Sole Proprietor ( ) Partnership ( ) Trust ( ) Charitable ( ) Other:
  Phone Number                                    Ext.
  Mailing Address
  Federal Employers Id (FEIN)
  Sales Tax Number

  Please provide all of the information requested above and submit to the address on this form. You will be contacted to schedule an
  inspection which is required prior to issuance of an Annual Food Permit.

IMPORTANT: Name and phone of Contact for Opening Inspection and opening date.
Contact Name and Phone Number:

Name of Applicant                                                                    Title

Date:                                          Opening Date: ____________________________

Do not submit more than two weeks prior to opening.
DACS-14221   6/05

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