Application For A Permit To Operate Food Service Establishment Form - Broome County Health Department
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1
2Broome County
Application for a Permit to Operate
Health Department
Food Service Establishment
FAILURE TO COMPLETE THIS APPLICATION IN ITS ENTIRETY WILL RESULT IN A DELAY OF YOU
RECEIVING A PERMIT TO OPERATE. OPERATING WITHOUT A PERMIT WILL RESULT IN
IMMEDIATE CLOSURE AND ENFORCEMENT ACTIONS.
**************************************************************************************************
Complete all items that apply to your establishment (all applicants must complete Sections A, B, F and G), sign on the
back page and return with the appropriate fee at least 30 days prior to the expected opening date to:
BROOME COUNTY HEALTH DEPARTMENT
PERMIT FEE: ___________________
ENVIRONMENTAL HEALTH SERVICES
225 FRONT STREET
** PLEASE ENCLOSE A CURRENT MENU**
BINGHAMTON, NY 13905
(607) 778-2847
Contact the Broome County Health Department at (607) 778-2847 if you have any questions.
Section A: Facility Information (Entire Section must be completed by all applicants).
Facility name
Facility address
City _________________________ State ___________________ Zip ____________ Telephone No. (____)
E-mail Address _____________________________________ Fax Number _______________________
Seating
Municipality/Town _________________________________
Capacity ___________
Facility Status: Profit / Non-profit
** FACILITY MAILING ADDRESS
IF DIFFERENT FROM ABOVE:
Water Supply
Sewage System
TYPE OF OPERATION UNDER THIS PERMIT
___ Public (municipal)
___ Public (municipal)
___ Restaurant ___ Mobile Unit ___ Temporary
___ Private (onsite)
___ Private (onsite)
___ Seasonal
___ Off-Premise Caterer
___ Other
(Temporary & Mobile Operations) Water Supply Where Water is Drawn ______________________________________________
Indicate days of operations:
Expected
Expected
Days of
Hours of
Opening date __________ closing date __________
the week: S M T W T F S operation ______ am/pm ______
am/pm
Month/Day
Month/Day
(Please circle)
Open
Close
Section B: Operator/Owner Information (Entire section must be completed by all applicants.)
Legal operator or operating corporation
Person in charge
Permanent address
City ______________________________ State __________ Zip __________
Telephone no. (____)
Emergency Contact ________________________________
Phone # _______________________
E-mail_______________________________________
Fax #__________________________
Owner
Permanent Address
City __________________________________ State ___________ Zip _____________ Telephone no. (____)
TURN OVER
MORE INFORMATION & SIGNATURE ARE REQUIRED ON BACK
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