Application For A Permit To Operate Allegany County Department Of Health
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1
2Application for a Permit to Operate
Allegany County Department of Health
7 Court Street, Belmont, New York 14813
A. Facility Information (Entire section must be completed by all applicants.)
Facility __________________________________________________________ Phone________________
Address__________________________________________________________
____________________________________________________________
Location (Town/Village)________________________________________ County Allegany
B. Operations Regulated by this Permit
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Permitted Operation(s):
Food Service
Bathing Beaches
Campgrounds
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Frozen Dessert
Indoor Pool
Day Camp
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Mobile Food Service
Other: ___________________
Fee Exempt _____________
Total Fee Due $_____________
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Capacity________________
Units:
Seats
Rooms/Units
Persons
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Sites
Swimmers
Beds
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In Operation:
Year-Round
Seasonal
Temporary
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Expected
Expected
Days of
Sun
Mon
Tues
Wed
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Opening date ________
Closing date _________
Operation:
Thur
Fri
Sat
Sun
Hours of Operation ____________ am / pm TO ____________ am / pm
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Water Supply:
Public (municipal)
Private (onsite)
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Sewage System:
Public (municipal)
Private (onsite)
C. Operator / Owner Information
(Check all that apply)
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Receives Application
Receives Mail
Responsible Person
Legal Operator or operating corporation ______________________________________________
(If corporation or partnership, Section G must be completed.)
Title ________________________
Person in Charge _____________________________________________ Phone ______________
Address__________________________________________________________
___________________________________________________________
E-Mail ______________________________________________________
Employer Identification Number ____-__________ OR Social Security Number ____-____-_____
Owner ______________________________________________________
Permanent Address___________________________________________
____________________________________________ Phone _____________
Alternate Address ___________________________________________
____________________________________________ Phone _____________
From: _____________________ To: ________________________
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