Application for Permit : Bureau of Food Safety and Community Sanitation : NYC DOHMH

The New York City Department of Health and Mental Hygiene

DOHMH HomeMy HealthMy Community's Health: Data and StatisticsHealth Topics A-Z - Chemical Dependency - Data and Statistics - Diseases and Conditions - Environmental Health - Family Health - Health Care Insurance - Mental Health - Mental Retardation - Public Health Services - Veterinary and Pest - Women's HealthCareer OpportunitiesContracting OpportunitiesPress Releases - Archive - En Español (Spanish) - 中文 (Chinese) - Creole - 한국 (Korean) - Français (French) - Русский (Russian) - اردو زبان (Urdu) - יידיש (Yiddish) - RSS FeedHealth Bulletins and Other PublicationsOfficial NoticesAbout DOHMH - Board of Health - Fund for Public Health - Language Access PlanEvent CalendarContact DOHMH

Application for Permit : Bureau of Food Safety and Community Sanitation : NYC DOHMH

Food Safety and Community Sanitation

Field Operations / Inspections

Application for Permit

If you are not registered to Vote where you live now, would you like to apply to register to vote here today?

Yes No

Applying, or declining to apply, to register to vote will not effect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration application, we will help you.

APPLICATION FOR PERMIT
Falsification of any statement made herein is an offense punishable
By a fine or imprisonment or both, (N.Y.C. Administrative Code 1151-9.0)

FOR OFFICE USE

Camis Number
|__|__|__|__|__|__|__|__|

Document Number
|0 |__|__|__|__|__|__|__|

FOR OFFICE USE

Permit Number

Type Number

|H |__|__| |__|__|__|__|__|__|__|

REASON FOR APPLICATION
code

N - New Permit
A - Amend
T - Terminate
W - Reactivate
L - Reissue Same No. APPROVAL STATUS

1. Approved
2. Pending
3. Disapproved
Fee
Amount
Dollars
__|__|__|__|__ Cents
__|__ Fee
Class
1 |__ Application Date
Mo__|__
Day__|__
Year__|__

Boro
Estab. Type
__|__ Division
District
__|__ Date Permit Issued
Mo__|__
Day__|__
Year__|__

Name of Permit
____________________________________________________________________________

THE UNDERSIGNED MAKES THE FOLLOWING STATEMENTS IN ACCORDANCE WITH PROVISIONS OF THE HEALTH CODE:
IMPORTANT:Please type of print legibly using capital letters. Allow spaces between completed words or numbers. Standard abbreviations are permitted. All sections must be completed. Section G is to be completed by all temporary food applicants.

Section A
Type of Ownership Section B
Check Days Closed/Enter Times Section C
Number of Seats

I - Indiv.
M - Municipal
P - Part
C- Corporation
Sun Mon Tues Wed
Thurs Fri Sat

Opening Time Closing Time

Section D - Name, Address and Telephone Number of Entity to which permit is to be issued

Read Carefully: Enter the Coporate Name and location of business establishment. If not incorporated, enter your name(s) and location of business establishment.

Name of Corporation, Partnership, Partners or Individual Owner (Last Name First)

Trade Name/DBA
Telephone Number
(area code)|__|__|__| - |__|__|__| - |__|__|__|__|

Building Number
Street
Premises Location (Floors, Store #, Booth #)

City or Town
State
__|__ Zip Code
|__|__|__|__|__|

Section E - Mailing Address if different from permitted estalishments address (include apartment #, P.O.Box #)

Street Address

City or Town State
__|__ Zip Code
|__|__|__|__|__|

Section F - E.I.N. Number Section G - Event Date (Temporary Feed Applicants Only) Rain Date

|__|__|__| - |__|__| - |__|__|__|__|
From
__|__ - __|__ To
__|__- __|__

From
__|__ - __|__ To
__|__- __|__

THE REMAINING SECTION APPLY TO ALL APPLICANTS APPLYING FOR A PERMIT

1. Name
Social Security #
Title

Home Address
Zip Code

2. Name
Social Security #
Title

Home Address
Zip Code

3. Name
Social Security #
Title

Home Address
Zip Code

4. Name
Social Security #
Title

Home Address
Zip Code

5. Name
Social Security #
Title

Home Address
Zip Code

6. Name
Social Security #
Title

Home Address
Zip Code

Signature of Applicant or Corporate Officer

Sign Here _________________________
Title Are you 21 years of age or over? YesNo

Telephone Number

FOR OFFICE USE ONLY

Action Taken by Division of Permist

Action Taken by Approval Units

Check (x)Approval Unit Application is set to

Dates

Sent

Returned

Radiological Health

Public Health Engineering

Inspections

Veterinary Public Health

Specify

Remarks:

Date

Initial

Disposition		Authorized Signature	Title
Approval -A Disapproval			Title
No	Date		Asst. Comm.





Remarks:

Reserved for Special Additional Data

CITYWIDE LICENSING CENTER - DEPARTMENT OF HEALTH - 42 BROADWAY, 5H FLOOR, NEW YORK, N.Y. 10004

314C (REV. 4/97)

June 2001

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