APPLICATION FOR FOOD ESTABLISHMENT PERMIT

 Your permit will not be issued unless the form is filled out correctly and in its entirety.

NAME OF ESTABLISHMENT ____________________________________________

LOCATION ADDRESS OF ESTABLISHMENT ______________________________

                                                                         _______________________________

PHONE NUMBER ______________________________________________________

MAILING ADDRESS ____________________________________________________

                                 _____________________________________________________

OWNER _______________________________________________________________

OWNER'S ADDRESS ____________________________________________________

OWNER'S PHONE NUMBER _____________________________________________

NUMBER OF EMPLOYEES ______________________________________________

Certified Food Handlers Name ____________________________________________

*NOTE: INCLUDE COPY OF FOOD HANDLER CERTIFICATE

IF OPEN ONLY PART OF THE YEAR, LIST MONTHS OF OPERATION __________

                                                      ___________________________________________

PERMIT FEE SENT _____________________________________________________

As of January 1, 2005, the State of Indiana requires that at least one person per establishment, who oversees food safety operations, be a “Certified Food Handler”, which means that a person in your food service establishment must pass an examination that meets the standards established by the Conference for Food Protection. Please bring or mail a copy of the person's certificate for your establishment so that it may be included in our files. An updated list of class providers is available at http://www.in.gov/isdh/21059.htm.