Daycare License Application Form
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1SPRINGFIELD TOWNSHIP APPLICATION FOR ANNUAL DAYCARE FOODSERVICE LICENSE
SPRINGFIELD TOWNSHIP
FOR OFFICIAL USE ONLY
50 POWELL ROAD
Payment Received__________________
SPRINGFIELD, PA
19064
610.544.1300
Expires___________________________
License#__________________________
Application is hereby made for a license to operate in Springfield.
Operator agrees that the
establishment will comply with the provisions of the Springfield Township Health Department Rules
and Regulations applicable to this type of establishment as stated in the PA Department of
Agriculture, Chapter 46, FOOD CODE.
It is further agreed that said establishment shall be open
to inspection by the Springfield Township Health Department.
Application for license renewal shall be made at least one month before expiration of existing
l
icense.
The license is not transferable.
PLEASE PRINT
«Notice»
Establishment
«BusName»
Daycare
«StNo» «StName»
«CSZ»
Proprietor’s *
Telephone ___________________
Owner Name ________________________
Fee:
$101.00
Address ___________________________
___________________________
Telephone ___________________
Manager’s Name_____________________
Est. # of children Per Day_______
Address_______________________________________________________________________________
Establishment hours____________________
Total # of employees:_______
Is food prepared on site?
Yes______
No______
If yes please provide a copy of a menu with this application.
Do you have a certified Food Manager?_____
Name:______________________________
CFM Certificate#____________
Expiration Date:_________
Please attach a copy of current certification
Give name & address of your PRIVATE GARBAGE/REFUSE COLLECTOR_________________________
_____________________________________________________________________________________
How often are collections made_________
Give name and address of your RECYCLING COLLECTOR____________________________________
How often are collections made_________________________
Give name and address of your EXTERMINATING SERVICE__________________________________
_____________________________________________________________________________________
How often are establishments exterminated_______________________
As required by PA Act 62 of 1992, all new establishments applying for license must submit proof
that application has been made or receipt has been acquired of a Sales and Use Tax License or
Exemption from the PA Department of Revenue: (check one and enclose copy):
____Sales & Use Tax
License;____Sales & Use Tax Exemption Certificate;____ Completed Sales Tax App.
I,___________________________________,
hereby,
certify
that
the
facts
set
forth
(Print name of Proprietor or Authorized Agent) on this application are true and correct to the
best of my knowledge.
I understand that the submission of false or misleading information is
grounds
for
legal
action.
________________________________________Date__________________
(Signature of Proprietor or Authorized Agent)
________________(Title of Proprietor or Authorized
Agent) *Proprietor is defined as the person, partnership, association or corporation conducting a
public food service facility.
If ownership is a partnership or corporation attach a list of all
partners
or
corporate
officers
along
with
their
home addresses and phone numbers.
Attention:**If any of your food is prepared off the premises include a copy of the current
license and latest inspection of the establishment where the food is prepared, as well as
verification by the establishment owner that your food is being prepared there.
Your application
will not be considered without these documents.
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