Registration For Food Processing Establishment - Illinois Department Of Public Health, Division Of Food, Drugs And Dairies

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ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Type of Food Processing
For IDPH use only
OFFICE OF HEALTH PROTECTION
☐Warehouse ☐Processor ☐Re-packer
State #
DIVISION OF FOOD, DRUGS AND DAIRIES
Establishment Size
Federal #
(Based on Gross Sales)
525 W. Jefferson Street
Wholesale
%
Springfield, IL 62761
Interstate Sales
%
Tier
dph.mfgfood@illinois.gov
REGISTRATION FOR FOOD PROCESSING ESTABLISHMENT
(USING BLACK INK, PRINT OR TYPE ALL REQUESTED INFORMATION)
☐New ☐Renewal ☐Ownership Change ☐Change of Address Previous Address
Facility Address
Facility Legal Name
County
D/B/A (if applicable)
Street Address
City
State
Zip+4
Phone
Fax
Cell
Other
Email
Web Address
Plant Manager
24 Hour Emergency Contact
Days and Hours of Operation
Source of Water (Private, Municipal, etc.)
Mailing Information
Mailing Name
Mailing Address
City
State
Zip+4
Facility Owner Address
Owner Name
Mailing Address
City
State
Zip+4
For IDPH use only
TITLE of INDIVIDUAL COMPLETING REGISTRATION
Date Received by IDPH:
☐Application reviewed and conditionals approval granted
pending inspections
PRINT NAME
☐Must be inspected prior to operating
☐Other
Signature:
Date:
SIGN NAME
Date notified:
Regional Offices
Rockford
Peoria
Edwardsville
Marion
Champaign
West Chicago
Bellwood
O: 815-987-7511
O: 309-693-5360
O: 618-656-6600
O: 618-993-7010
O: 217-278-5900
O: 630-293-6800
O: 708-544-5300
F: 815-987-7822
F: 309-693-5118
F: 618-656-5863
F: 618-993-7052
F: 217-278-5959
F: 630-293-6908
F: 708-544-4395

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