Food Application for Permanent, Seasonal or Mobile Permits

New food establishments and remodels must submit a Plan Review and have a Pre-Operational Inspection
prior to a Permit being rendered.
	 $150.00 New Permanent, Seasonal, or Mobile Units operating more than 6 months
	 $100.00 Renewal Permanent, Seasonal, or Mobile Units operating for more than 6 months
	 Late fee (50% of original fee)
	 $50.00 Seasonal or Mobile Units operating for less than 6 months
	 Late fee (50% of original fee)

Food Establishment Name 				 Address 				 City 	State 	Zip 	  Manager’s Name 		 Phone 		

Is the food establishment connected to a well? 	

(Water reports need to be submitted annually)

Owner Name 			Phone 		 Address 				City 			 State 	Zip 	Email 				 Emergency Contact 				Phone 	 

License Food Handler Certificate Required		Yes		No
(If yes, a copy of your certificate must be on file with the Health Department)

Check all goods that apply to your establishment:
	Raw Meat		Baked Goods		Reheated/Precooked		Prepackaged

Days and Hours of Operation:
	Sun 	Mon 	Tues 	Wed 	Thurs 	Fri 	Sat

Seasonal/Mobile Event:
	 Location: 	
	 Location: 	
	 Location: 	

Date: 	 Date: 	  Date: 	

I hereby certify the above is correct and the food service facility will be maintained in compliance with the Food Establishment and/or Bed and Breakfast Establishment Ordinance, Fountain County 2018-3.
I understand the food establishment permit is non-transferable and will be kept posted on the above-mentioned premises. I understand that fees associated with the application and permit are non-refundable.
NOTE: It is the sole responsibility of the permittee to obtain an application for renewal or change in ownership/ operator by December 31st.
A late fee will be assessed if payment is received after December 31st. All fees will need to be paid in full before permit is granted. All fees are subject to change. Please verify current fees directly with the Health Department.

Signature 	 Date