Docstoc

Food Permit App

Document Sample
Food Permit App Powered By Docstoc
					                                                                                                 Permit #______________

                                                                                                 Priority:   H       M      L
                                                                                                             (circle one)


                             APPLICATION FOR FOOD ESTABLISHMENT PERMIT
According to the applicable codes and ordinances:
1. No person shall operate a restaurant that does not have a current and valid permit issued to him by the Director of this
   Department.
2. Establishments must comply with the requirements of this Code to receive or retain such a permit.

This application is for (check all that applies):
□Establishment in City of Springfield city limits (Permit Fees Apply call or visit web site for current fee schedule)
□New owner of existing facility     □An existing facility being remodeled         □Existing facility         □New construction
Water Source: □ Public □Private              Waste Water: □ Public □ Private

                                           FOOD ESTABLISHMENT INFORMATION

Food establishment name: ________________________________________________________________

Food establishment address: _______________________________________________________________
                            Street                         City                     Zip Code
Telephone# (_______)__________________________Fax# (_____)_______________________________

Email address: _________________________________________________________________________


                                                    OWNER INFORMATION

Owner/Corp: ___________________________________________________________________________

If Corporation list CEO: ___________________________________________________________________

Mailing address/billing address (if different from above):

______________________________________________________________________________________
           Street                                 City                      Zip Code

Telephone# (_______)__________________________Fax# (____)________________________________

Email address: _________________________________________________________________________



SIGNATURE OF APPLICANT________________________________________________ DATE________________


PRINTED NAME OF APPLICANT___________________________________________________________________

Please return application to:
Springfield-Greene County Health Department                                                     Phone: (417) 864-1424
Food Compliance                                                                                 Fax:   (417) 864-1104
320 E. Central St.                                                                              www.springfieldmo.gov/health
Springfield, MO 65802

Revised 12/20/11                                                                                Approved 12/20/2011
LLB                                                                                             RMS

				
DOCUMENT INFO
Categories:
Tags:
Stats:
views:1
posted:8/17/2012
language:Latin
pages:1
PermitDocsPrivate PermitDocsPrivate http://
About