Application For One Stop Retail Food Establishment License - Montana Department Of Public Health & Human Services
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2FR -
MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES
FOOD & CONSUMER SAFETY SECTION - (406) 444-2408
APPLICATION FOR ONE STOP RETAIL FOOD ESTABLISHMENT LICENSE
Establishments with 2 or fewer employees working at any one
Establishments with more than 2 employees working at any
time ($60 license fee) RPF1X
one time ($90 license fee) RPFBX
This application includes all types of food establishments that are regulated by ARM Title 37, Chapter 110, Subchapter 2
Note: By provision of 50-50-201, MCA, one license fee includes all types of retail food establishments operating on the same premises
when they are operated by the same licensee. Only remit one license application fee for each retail premises location. Food
Manufacturing Establishments are licensed separately and must submit separate application with appropriate fees.
HEALTH OFFICIALS RETURNING “PREVIOUSLY PAID” APPLICATIONS ONLY REQUIRING SIGNATURE, OR REQUESTING
“ENDORSEMENT CHANGE”, PLEASE RETURN TO: MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES or
(DPHHS). MAIL to DPHHS at: DPHHS/FCSS, PO BOX 202951, HELENA, MT 59620-2951
PLEASE PRINT
Licensee (Operator/Owner) Name: _____________________________________________________________________________
Establishment Name: _______________________________________________________________________________________
Establishment Location Address: ______________________________________________________________________________
City: _______________________________________
Zip Code: _____________
County: _____________________________
Mailing Address (If different from above): ________________________________________________________________________
City: _______________________________________
State: ____________________
Zip Code: ______________________
On-Site Operator/Manager Contact Name (if different than Licensee Name): ____________________________________________
Contact Telephone: ( _____ ) ______- ________
Contact FAX: ( _____ ) _____ - ________
Contact E-mail address: _____________________________________________________________________________________
This Section is to be completed and signed by the Local Health Authority Only!
Type of Establishment: (Check one or more - fee same regardless of number checked)
1.
Food Service Establishment
8.
Water Hauler
3.
Meat Market (Onsite Retail Only)
9.
Perishable Food Dealer (Retail only)
4.
Bakery (Onsite Retail Only)
10.
Food Service/Catering (Retail)
6.
Food Manufacture (Onsite Retail Only)
11.
Food Service/Delicatessen (Onsite Retail)
7.
Mobile Food Service
12.
Produce (onsite retail only)
Change type of establishment (endorsement) _____________________________________________________________________
Seasonal:
Yes or
No
If Yes, Dates Open: ____________________________ To ________________________________
Public Water Supply:
Yes or
No
PWSID No: ___________
Private (Not Public) Water Supply:
Yes or
No
Public Sewage Treatment System:
Yes
or
No
Private (Not Public) Sewage Treatment System:
Yes or
No
Existing Facility:
Yes or
No
New Construction:
Yes or
No
Remodeled:
Yes or
No
Preconstruction Review Plans approved by local or state health authority?
Yes,
No,
or
NA
Fire Authority Approved:
Yes,
No,
or
NA
Building Authority Approved:
Yes,
No,
or
NA
Pre-opening Inspection completed and approved:
Yes
or
No
Previously Licensed:
Yes or
No
If Yes, then Former Name: _________________________________________________
Previous License Number: _____________________
Last Calendar Year Licensed: __________________
License Limitation/Condition/Comment Statement: _________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
(The statement above will appear on the printed license. It will identify condition(s) or limitations on the license’s approval.)
APPLICATION APPROVED: ______________________________ DATE: ___________ COUNTY: _________________________
(Local Health Authority Signature Required)
(Rev. 11/07)
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