Food Safety and Community Sanitation

Field Operations / Inspections

Instructions for Completing the "Application for Permit"

New York City Health Code Section 3.19 states:

No person shall make a false, untrue or misleading statement or forge the signature of another on a certificate, application, registration, report, or other document required to be prepared pursuant to this Code. No person shall make a false, untrue or misleading oral statement to the Department as to any matter investigated by the Department.

All information provided as part of the application package must be either typed or printed clearly in ink. Information not provided in this format will not be accepted.

Complete all sections.

Enter the type of establishment (from Food Establishment Classification and Fee Schedule) you will be operating, next to "Name of Permit".

SECTION A

• Enter type of ownership.

SECTION B

• Check the days when the business is closed, if any, and enter the general opening and closing times of the business.

SECTION C

• Enter the number of seats provided for customers. Include all seats within the establishment used by customers, including seating in a restaurant/bar area and seats at the bar itself. If there are no seats, enter 'none'.

SECTION D

• Enter the individual owner's name, or all partners' names, or corporation name in the box labeled 'Name of Corporation or Individual'.



• Enter the name of the establishment in the space labeled 'TRADE NAME/D.B.A.'.



• Enter the address where the establishment is actually located. Please include in the space labeled 'Premises Location' the floors, booth #, or store # where the establishment is to be located. When entering the floors which the establishment occupies or uses, use: 'B' for basement, 'C' for cellar, '1' for 1st floor, '2' for 2nd floor, 'M' for mezzanine, 'L' for lobby, etc.

SECTION E

• Enter the mailing address if different from the address where the establishment is to be located. All correspondence, including the permit and renewal notices will be mailed to that address.

SECTION F

• Enter Employee Identification Number (E.I.N.) or New York State Tax ID number. For individual ownership only, enter the owner's social security number.

SECTION G

• To be completed by applicants for Temporary Food Service Establishment Permits only.



• Enter both the date when the event will begin, and the date when the event will end. In addition, enter the rain date(s) for the event, if applicable.

SECTION H (On Reverse Side of Application for Permit)

• Enter the name, home address, zip code, social security number, and title (e.g., sole owner, partner, president, vice president, secretary, treasurer) of the owner, or of all partners in the business, or of all principal officers in the corporation.



• Enter the title and telephone number of the person who signed the Application for Permit (e.g., sole owner, partner, president, vice president, secretary, treasurer).



• Enter whether the applicant is 21 years of age or over.

Signature:The person who signs the Application for Permit must be named in Section H or have Power of Attorney to sign on behalf of the applicant.

June 2001

For more information on Inspections, call 212-676-1600.