Fill and Sign the Summer Camp Scholarship Application Sampledoc Co Henrico Va Form

GEORGIA DEPARTMENT OF PUBLIC HEALTH Hall County Environmental Health 450 Prior Street, Gainesville, Georgia 30501, Phone: (770)531-3973, Fax: (770)531-6767 Application for Food Service Establishment Permit ________________________________________________________________________________ Name of Establishment Business Phone # Fax # Email ________________________________________________________________________________ Location of Establishment (Street Address) City State Zip ________________________________________________________________________________ General Mailing Address City Check appropriate block: Take Out Service Operation Camp Restaurant Coffee Shop State Mobile Food Unit Sit Down Meals Caterer Bar/Lounge Intinerant Vendor Concession Stand School Zip Temporary Food Service Restricted Food Single Service Only Cafeteria Other: ____________________________________ Mobile Food Unit--VIN:________________________________ Tag #______________________ ________________________________________________________________________________ Business Owner/Corporate Name Phone # Fax # Email ________________________________________________________________________________ Business Owner’s Mailing Address City County State Zip ________________________________________________________________________________ Authorized Agent Name Phone # Fax # Email ________________________________________________________________________________ Authorized Agent’s Mailing Address City County State Zip ________________________________________________________________________________ Name of Party Responsible for Fees Phone # Fax # Email ________________________________________________________________________________ Billing Mailing Address If mobile unit: City County State Zip _____________________________________________________________________ Commissary Name Contact Name Phone Number _____________________________________________________________________ Commissary Street Address City County State Zip If permit is for TEMPORARY or RESTRICTED Food Service Operation only, give the following: Date operation to begin_______________, 20___ Date operation to close_______________, 20___ Has your establishment been thru plan review? Water Supply: Public Water No Individual well Yes When? ______________________ Community System Spring Other: _____________________ Sewage Disposal: Public Sewer Individual On-site System Other: ___________________ On-site permit #: __________________ Grease Trap: Yes No Estimated number of meals served per day: _______________ Number of seats: _______________ What are your hours of operation? _______________________________________________________________________________ Person to call if an English speaking employee is not in the establishment during the inspection: Name: ______________________________________ Phone number: _______________________ YOU MUST ATTACH A COPY OF YOUR MENU TO THIS APPLICATION It is the responsibility of the applicant to verify with other State or County departments (i.e. Business License, Planning & Zoning, Building Inspection) to insure all regulations are met. The undersigned hereby applies for a permit to operate a Food Service Establishment pursuant to the OCGA 26-2-371-373 and hereby certifies that he has received a copy of the Rules for Food Service, Chapter 290-5-14, Georgia Department of Public Health. _____________________________________________________________________________ Signed Business owner - or- Authorized agent Date C:\Users\Paul Herriott\Desktop\Website Info 7-18-11\Website Info 7-18-11\Food Service Permit Applicaion 2011.doc