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FOOD SERVICE APPLICATION FORM

Decatur County Health Department

801 N. Lincoln Street

Greensburg IN 47240

(812)663‐8301 Fax (812)663‐4174

The following information is REQUIRED if applicable. Please return this completed form with page one.

Name of Establishment:____________________________________________________________________

Number of Seats____________________________ Total Square Footage____________________________

TOTAL Number of Employees__________________ Managers___________ Food Handlers______________

Waiters__________________ Deliverers____________

Estimated Number of Meals served weekly____________________________

Meals Served (check all that apply)





Breakfast

Lunch

Dinner

Cater

Mobile Unit



Days and Hours of Operation

Day

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Opening

Time

Closing

Time

The Undersigned Hereby applies for a permit to operate a Food Service Establishment pursuant to Decatur County Ordinance 2006‐4. The undersigned hereby attests

to the accuracy of the information provided in this application and affirms that the undersigned will comply with the ordinance, and allow the Decatur County Health

Official full access to the establishment.

Signature of Applicant(s):

Printed Name of Applicant(s):

********* Please enclose copies of menus and food handler certifications. *********

Permits are $40 for all Bed and Breakfast, Retail Food and Mobile Permits.

Please make check payable to:

Decatur County Health Department