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FSI-463-15 (03/15)

(5) Has the applicant or any partner, officer, director or stockholder been convicted of, or pleaded guilty to, a felony in any court in the United States?

Yes If yes, state the full name of the person __________________________________________________________________

Name of Court and its location? _____________________________________________________________________________________________

Date of Conviction? _________________________________________ A “Certificate of Conviction” is required. If a “Certificate of Conviction” has

been provided and a license issued on a prior application, check this box.

(6) Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation

Insurance (WCI). Indicate your WCI status:

Insured with _____________________________________________

Self Insured

Exempt from WCI

Name of Insurance Provider

The undersigned applies for a license to conduct a food salvager business at this location only, pursuant to Article 17-B of the Agriculture and Markets

Law of the State of New York and in support of this application agrees to comply with the requirements of Article 17-B and with the rules and regulations

promulgated pursuant thereto.

The applicant represents that there are adequate physical facilities to conduct a food salvage business at the location for which this license application is

made.

Applicant consents to free entry and will permit free access to the licensed premises, buildings and offices to the Commissioner, the Commissioner’s

agents and inspectors in pursuance of the Commissioner’s duties to supervise and regulate the production, storage, sale and use of articles subject to

the Commissioners jurisdiction.

Applicant understands the statements made in the application will be accepted, for all purposes, as the equivalent of an Affidavit.

Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application may be

punishable under the provisions of Section 210.45 of the Penal Law of the State of New York.

(7)

TITLE

DATE

ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER

AUTHORIZATION AND PURPOSE

Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State

Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been

delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the

Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law.

The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific

license you are seeking. This information is collected to enable the Department to evaluate your application, to determine if it should be issued and to

assist in the enforcement and administration of the Agriculture and Markets Law.

All fields must be completed. Incomplete applications may not be processed. If you have questions about

the information requested, call (518) 485-5326; or write to: Department of Agriculture and Markets; FSI-

Licensing Unit; 10B Airline Drive; Albany, NY 12235.

Fsi-463-15 - Application For Food Salvager License - Nys Department Of Agriculture And Markets Page 2

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