Food Service Application Form
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2FOOD SERVICE APPLICATION FORM
Decatur County Health Department
801 N. Lincoln Street
Greensburg IN 47240
(812)663‐8301 Fax (812)663‐4174
Please send this form along with your payment on or before January 1, 2016. If you are requesting tax exempt status, please submit a copy of your 501 c 3. Fill out
this form as you want it to appear on your permit. An incomplete form will not be processed for a permit. A late fee may be assessed at $20 for every 45 days in
addition to the permit fee. Please enclose a copy of your entire menu. Permits are $40 for all Bed and Breakfast, Retail Food and Mobile Permits.
Facility Name (As it will appear on permit)
Phone ( )__________________
Fax ( )__________________
Facility Address:
City: ___________________________
E‐mail: _________________________
Zip Code: _______________________
Website: _______________________
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Food Service Operation Classification :
Bed and Breakfast
Retail Food
Mobile
OWNERSHIP INFORMATION
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Ownership Legal Type:
Association
Corporation
Individual
Partnership
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Non‐Profit
Other________________________
(please include 501c3)
Owner’s Name:
____________________________________________________
Owner’s Phone ( )_________________________
Address:
____________________________________________________
Owner’s Cell Phone ( )_______________________
Owner’s Email __________________________________
City:_________________________ ST:____ ZIP :____________
MANAGEMENT INFORMATION
Person in Charge has the oversight of a zone, district or region.
Name of person in Charge:
Title: ______________________________________
Telephone:__________________________________
Operator has oversight of the preparation or serving of food at the establishment.
Name of Operator:
Title: ______________________________________
Telephone:__________________________________
Enclose copies with application
Name(s) of Certified Food Handler(s):
Date of Exam:
MAILING ADDRESS
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Please send all future correspondence via email
Address for correspondence, including application or email address if you prefer:
Name
_______________________________________
Email Address ______________________________________
Address
_______________________________________
City___________________________________________ ST: __________________ ZIP _______________
Office Use Only
Establishment #
Menu Type
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Parent category: Business