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Worker’s Compensation and Disability Insurance Information

(Proof of insurance is required prior to permit issuance)

Workers' Compensation: Check and Submit Certificate with Application



Form C-105.2 – Certificate of Worker's Compensation Insurance (issued by the applicant's insurance carrier); OR



Form U-26.3 – Certificate of Workers' Compensation Insurance (issued by the State Insurance Fund); OR



Form SI-12 – Certificate of Workers' Compensation Self-Insurance, OR



GSI – 105.2 – Certificate of Participation in Workers' Compensation Group Self-Insurance

AND

Disability Benefits: Check and Submit Certificate with Application



DB-120.1 - Certificate of Disability Benefits (issued by the applicant's insurance carrier); OR



Form DB-155 – Certificate of Disability Benefits Self-Insurance

*NOTE- WE CANNOT ACCEPT THE “ACORD CERTIFICATE OF LIABILITY” AS PROOF OF INSURANCE.

When WC/DB coverage IS NOT provided: Check and Submit Certificate with Application



Form CE-200 – Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits

Coverage (Must be submitted with Application if WC/DB coverage is Not provided)

Note: Applicants will be able to fill out the CE-200 on line at the Worker’s Compensation Board’s website,

(use the CE-200 (12/08) and print a copy for submission to the Department of Public Health. Computers with internet access are available

for CE-200 electronic application processing at Customer Service Centers located in Worker’s Compensation Board District offices. A

local District Office is located at 130 West Main St., Rochester, NY 14614. The toll free number for the office is 1-866-211-0644.

Mobile Food Service Information

(Fill out if ‘Mobile Vending’ or ‘Pushcart’ is checked on Page 1)

Type of Vehicle  Motorized  Pushcart  Other (specify) ____________________________________________

Commissary Name: __________________________________________________________________________

 Letter

 MCWA  Other: ___________________ Size of water supply tank: ________ Size of waste tank: _____

Source of Water:

Is the water tank and plumbing NSF approved (food grade)? ________________________________________________________

 Photo of interior / or drawing of equipment layout for mobile trucks

 Photo of exterior of mobile truck or pushcart

Where do you plan to set up? _____________________________________________________________________________

When do you plan to operate?  weekdays  weekends  evenings  winter or any time when temperatures are 32°F or <

Check the foods you are planning to serve:

 Hot dogs  Hamburgers (commercial pre-formed)  Pre-cooked sausage

 Pre-cooked chicken  Shaved frozen steaks  Commercial hot sauce

List any other types of food you would like to be considered for approval of service:

_________________________________________________________________________________________________________________________

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Application For A Permit To Operate A Food Service Establishment Form - Monroe County Department Of Public Health Page 2