Application For License To Operate A Food And Lodging Establishment Form
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1
2Food & Lodging Program
For office use only:
108 Cherry Street
P.O. Box 70
Burlington, VT 05402-0070
ID #_________
802-863-7221
APPLICATION FOR LICENSE TO OPERATE A FOOD AND LODGING ESTABLISHMENT
New Establishment
ESTABLISHMENT
NAME (dba): __________________________________________________________________
Previously Licensed Location
FULL LEGAL NAME OF
Ownership Change
CORPORATION, LLC OR
Renewal
OWNER(S):___________________________________________________________________
PHYSICAL
ESTABLISHMENT
ADDRESS: __________________________________________________________ PHONE:________________________________
MAILING
ADDRESS:_________________________________________________________________________________________________
EMAIL:_______________________________________________________________ OFFICE PHONE:________________________
Person to contact regarding
this application and inspection:__________________________________________________ PHONE:________________________
This location was a previously
licensed establishment known as:
EXPECTED OPENING DATE:
IF SEASONAL, OPENS:
CLOSES:
PUBLIC BUILDING OR WASTEWATER PERMIT # AND DATE ISSUED: ___________________________________________________
WATER SYSTEM OWNER/OPERATOR NAME:_______________________________________________________________________
ANR
WATER SOURCE TYPE:
Public
Private
WSID #:
SEWAGE DISPOSAL TYPE:
Public
Private
CHECK ALL LICENSES YOU ARE APPLYING FOR:
NUMBER OF RESTAURANT SEATS: _________
Restaurant (1-25 seats)
$105.00
TOTAL LODGING CAPACITY: _________
Restaurant (26-50 seats)
$180.00
Restaurant (51-100 seats)
$300.00
Restaurant (101-200 seats)
$385.00
Food Processor (Gross receipts <$10,000) no license required
Restaurant (201- 599 seats)
$450.00
Food Processor (Gross receipts $10,001-$50,000)
$175.00
___Restaurant (600 or more seats)
$1000.00
___ Food Processor (Gross receipts >$50,000)
$275.00
Home Caterer
$155.00
Children’s Camp
$150.00
Commercial Caterer
$260.00
Commercial Caterer – Push Cart
$260.00
Seafood Vendor
$200.00
Commercial Caterer – Mobile Unit
$260.00
Shellfish Reshipper/Repacker
$375.00
Limited Operation
$140.00
Lodging (Capacity 1-10)
$130.00
___Lodging (Capacity 11-20
$185.00
Home Bakery
$100.00
Lodging (Capacity 21-50)
$250.00
Small Commercial Bakery
$200.00
Lodging (Capacity 51-200)
$390.00
Large Commercial Bakery
$350.00
Lodging (Capacity 201 +)
$1000.00
FOR OFFICE USE ONLY:
Date Received ______________________ Amount $________________ Inspector Assigned _________________________
***PLEASE READ AND COMPLETE REVERSE SIDE***
07/2015
MAKE CHECKS PAYABLE TO VERMONT DEPARTMENT OF HEALTH
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