NEW Permanent Food Establishment Permit

Permanent Food Establishment Permit
This form is for NEW PERMANENT food establishments only.
OWNER INFORMATION
Name*

First NameLast Name
Physical Address of Establishment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
BUSINESS INFORMATION
Desired Opening Date*
Name of Business/Organization*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Anticipated days and hours of operation

Rows	Start Time	End Time	Comments
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

YesNo
Please list all changes to food services*
Name of Manager*

First NameLast Name
Number of "Persons In Charge" with a Certified Food Manager's Certificate*
Number of Staff with a Safe Food Handling certificate*
Serving Information
Average # of meals anticipated to be served daily*
Average # of meals anticipated to be delivered daily*
Food Storage
YesNo
Hot Water
Location of Hot Water Heater*
Hot water capacity-Gallons
Dish Washing

You MUST have a commercial dishwasher OR a 3 compartment sink. You MUST have a handwash sink that is easily accessible in all food prep areas. You must have a mop sink. The 3 compartment sink and the prep sink MUST have indirect plumbing.

Mechanical Dishwasher

Rows	Make	Model	Type	Type of Sanitizer to be used
Dishwasher

Sink information*

Rows	Three Comparment	Hand Wash Sink	Prep Sink	Mop Sink
Sink

YesNo
You answered no to: Will your largest utensil fit into each compartment of the sink.

Your three compartment sink must be able to contain at least 50% of the largest piece of equipment you have to wash. This does not include large equipment that you clean in place.

If you have a mechanical dishwasher and no three compartment sink, the largest item must fit into the dishwasher.
YesNo
Name and address of refuse company, and frequency of pick-up. If linens are not laundered on-site: Name and address of company *
Proposed Menus

You MUST submit the following items. I have set this application up so you can upload the information or type it in. If this is not provided you will not be approved for a permit until it is.
Upload proposed menus: Including seasonal, off-site & banquet menus

Cancelof
Site Plans/Equipment
Upload Diagram of establishment showing equipment, plumbing, electrical, and mechanical services. Architectural plans or hand sketches are acceptable*

Cancelof
Upload site plan showing location of food establishment, outside equipment, dumpsters, and grease receptacles.*

Cancelof
Upload equipment schedule (list of equipment including model and specifications)

Cancelof
YesNo
Upload: Provide HACCP plan for the following specialized processing methods: Reduced oxygen packaging/vacuum packaging, use additives to render a food non-potentially hazardous, curing and smoking preservations, molluscan shellfish tanks, and other specialized processing. **These processes MUST be approved before using them***

Cancelof
Are floors, walls, and ceilings smooth, non-absorbent, and easily cleanable? List materials used. *
I will send payment: $100I Will pay online: $105

My Products

Food Permit

$100.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

I hereby certify that the information provided is correct, and I fully understand that any deviation from this information without prior permission from Pike County Health Department may nullify final approval. I understand that the permit application is only good for 90 days and that fees are non-refundable. Approval of these Plans and specifications by this Regulatory Authority does not indicated compliance with any other code, law or regulation that may be required by federal, state, or local. If further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place and operational will be necessary to determine if it complies with he laws governing food service establishments and is required prior to establishment opening.
Signature

Powered by Jotform SignClear
Should be Empty:

Permanent Food Establishment Permit

OWNER INFORMATION

BUSINESS INFORMATION

Serving Information

Food Storage

Hot Water

Dish Washing

Proposed Menus

Site Plans/Equipment

Credit Card