FULTON COUNTY HEALTH DEPARTMENT
125
E. 9th ST. ROCHESTER, IN.
46975
Phone: 574-223-2881 Fax: 574-223-2335
APPLICATION FOR A FOOD SERVICE PERMIT
RETAIL OR BED AND BREAKFAST
Application is hereby made for a permit to operate a food establishment in Fulton County. By this application it is agreed that the establishment will comply with the provisions of the Indiana State Department of Health Rule 420 IAC 7-24 and Fulton County Food Ordinance 080502 or any subsequent
regulations. It is further agreed that the establishment
will be open to inspections by the agent of the Fulton County Health
Department. Application for permit renewal shall be made prior to the
expiration date of the existing permit. A
$70 fee will be due when the permit is issued or renewed.
Any change of ownership, location or operator requires a new permit. All permits expire December 31st of each year.
You must fill out this form
completely and accurately. This form must be signed and returned before the
permit will be issued. Form must be
returned by January 31 of current year.
A $500 penalty may be issued for failure to comply.
Name of
Establishment:_____________________________________________________
The name commonly used or “doing business as” name.
Establishment
address:_____________________________________________________
City ______________________________ State____________ Zip_____________
Establishment mailing address if
different_____________________________________
City _____________________State
___________Zip______________
Business Telephone: ____________________-
Owner or Owners (this should include anyone involved,
example
partner)_________________________________________________________________
If corporate owned:
Name and Address of central
office___________________________________________________________________
On site
manager__________________________________________________________
The person responsible for daily operations.
Building owner name:
_____________________________________________________
Person responsible for physical structure
What is the owner responsible
for?____________________________________________
Building owner’s
address___________________________________________________
Building owner
telephone___________________________________________________
Number of employees__________________________
Emergency contact
person_________________________________________________
Emergency Phone________________________________________
Please submit menu if applicable:
Do you cater?
Yes________ No ________
If yes, is Proper Equipment available for safe food
handling and handwashing?
How is food transported? What is done
with leftover food?
Public Water Supply _______Yes ______ No
Well water please mark no
“Smoke Free Establishment” Yes _____
No ____
CERTIFIED FOOD HANDLER
________________________________________
Expiration Date
_______________________________
Signature :____________________________________ Title: ____________________
( Person completing form needs to sign)
Print Name: ____________________________ Date:______________________
For
official use only
Menu Type
1
2 3 4
Date
Issued: _________________________________
Date
Expires:__________________________________
Permit
fee paid:__________________________
Comments: