Retail Food Permit Application Form - Camden County Division Of Environmental Health

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CAMDEN COUNTY DIVISION OF
OFFICE USE ONLY
Permit #: ______________
Date Received: /
/
ENVIRONMENTAL HEALTH
Risk Type:______________
Food Handler Cert Rec’d Y/N
DiPiero Center, Suite #301
Select Permit Type:
512 Lakeland Road
Blackwood, NJ 08012
Existing Food Facility
Year established / /
Phone: 856-374-6052 Fax: 856-374-6211
Change of Ownership
(If you are a new owner since the
Previous name of facility: _______
last posted inspection)
New Establishment
Remodel/change of operation
Please print legibly!
Other: _____________________________
RETAIL FOOD PERMIT APPLICATION
*
OWNER INFORMATION
Corporation
Partnership
FACILITY INFORMATION
Single Proprietor
Association
Facility Name: _____________________________________
Other legal entity:___________________________________
Municipality: ________________________________________
__________________
Corporate/Owner Name:
Names (Owner, Corp Officer, Partners, etc.)
Title:
Facility Location: ____________________________________
no
street
________________________________________________________________
city
NJ
zip
Facility Mailing address
FOOD HANDLER CERTIFICATION INFORMATION
(if different from location):
zip
Your Risk classification is:
1
2
24
3
34
Facility Phone #:
Fax #:
ALL Risk 3 and 34 Establishments must submit a copy of a current
“Food Protection Manager Certificate” to the Health Department
for your designated Person in Charge (PIC)
Email address:
Course completed:
ServSafe ( )
*
Owner Name: ___________________________________
Thompson Pro-Metric ( )
(
)
National Registry of Food Safety Professionals
Owner Address: ___________________________________
no
street
city
zip
Name of Certified Food Handler
Certification Exp Date:
Owner Phone #:
Emergency #:
(PIC):
If you have a Risk type 3 or 34 menu, a new owner must
obtain certification prior to opening.
Tax ID Number:
Name/Title of person responsible for daily operations:
Sewage and Water
Water Source (circle one)
Sewage System (circle one)
Public
Private Well
Public
Septic System
Operation Details
Days of Operation: M T W T F S S Hours:
No. of Employees:
Meals per day:
Type of Operation (circle all that apply):
Prepare foods for next day service
juice/snacks only
Institutional (health, childcare, adult, education)
Deli items
Handles/cooks raw meat/fish
clients bring their own food
Commissary for mobile/temp events
Full service restaurant
●use
Heat/serve commercially processed foods
100%disposables
Church/social club
Prepare foods for off-premise serving
Foods are cooked/served for immediate consumption
Wholesale to other food businesses
Limited preparation for food that is hot held
Grocery with commercially prepackaged goods
Complex preparation (cook, hold, serve, cool, reheat)
Other: __________________________________________
●no food preparation: food delivered from vendor/commissary
I, the undersigned, attest to the accuracy of the information provided in this application.
Print Name:
Signature:
Date:

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