Fillable Printable Food Licence Application Form - New York

Food Licence Application Form - New York

FSI-303-15 (3/15)

Office Use Only

County Code- Est. No.

Entity No._________________

Receipt No.________________

Certificate No.______________

APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE

NYS Department of Agriculture and Markets - Article 20-C

License Fee $400.00

PROJECTED OPENING DATE: __ __ / __ __ / __ __

INSTRUCTIONS

Read and complete both sides of this application.

Prepare a separate application for each location.

Include license fee by check or money order payable to

“Department of Agriculture and Markets” and mail to

NYS Department of Agriculture and Markets, Attn:

License Unit, 10B Airline Drive, Albany, NY 12235.

An original signature of owner or corporate officer is

required in Section (9).

This application is only for those establishments that prepare or process food at the location listed below. Inspections are scheduled after

applications are received and reviewed. No license will be issued until an establishment receives a satisfactory inspection.

(1) Individual Owner Name, Partnership or Full Name of the Corporation:

County:

Trade Name:

Business Telephone Number:

( )

Street:

City:

State:

Zip:

E-mail Address:

Bank Name:

(2) Optional Mailing Address:

Street:

City:

State:

Zip:

(3) Identification Number:

Federal ID Number: OR Social Security Number:

(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members

(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).

Name (Please Print)

Title

Contact Address (Street & No., City, State, Zip)

E-Mail address

Date of Birth

(4a.) Principal Office Address: ______________________________________________________________________________________________

(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation _____________________________________________

(4d.) Are you a foreign or out-of-state individual, partnership, or corporation? (Check One) Yes No 

(4e.) For foreign or out-of-state corporations:

Date of filing in New York State? ____________________

(4f.) If out-of-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below which shall

constitute good and proper service of process.

Designated:_____________________________________ Address: _______________________________________________________

(PLEASE COMPLETE REVERSE SIDE)

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(5) Has the applicant or any partner, officer, director or stockholder been convicted of, or pleaded guilty to, a felony in any court in the United States?

Yes If yes, state the full name of the person ____________________________________________________________________

Name of Court and its location?________________________________________________________________________________________________

Date of Conviction? _________________________________________ A “Certificate of Conviction” is required. If a “Certificate of Conviction” has

been provided and a license issued on a prior application, check this box.

(6) List all food preparation or processing activities and the food prepared or processed at this location to be covered by this license. For example:

cook or heat foods, grind meats, slice cold cuts, cheese, fish, fruit, etc., cappuccino machine, repack ready-to-eat foods or ice.

_________________________________________________________________________________________________________________________________________________________________

(7) Retail Food stores applying for food processing establishment licenses must submit a copy of its certificate indicating that an individual in a position of

management or control assigned to the store has successfully completed an approved Food Safety Course. The following retail food stores are exempt

from this requirement:

a. Food stores that have as its only full-time employees the owner or the parent, spouse or child of the owner, or in addition not more than two full-time

employees.

b. Food stores that had an annual gross income of less than $3 million in the previous calendar year, excluding petroleum products, unless the food store

is part of a network of subsidiaries, affiliates or other member stores, under direct or indirect control, which, as a group, had annual gross sales of the

previous calendar year of $3 million or more.

Check one of the following:

__________ The retail food store is exempt from this requirement

__________ A copy of our Certificate is enclosed with this application

(8) Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation

Insurance (WCI). Indicate your WCI status:

Insured with __________________________________________________ Self Insured Exempt from WCI

Name of Insurance Provider

The undersigned applies for a license pursuant to Article 20-C of the Agriculture and Markets Law of the State of New York to conduct the food processing

operations listed above, at this location only. New or additional food processing activities are to be reported to this Department for approval prior to the

start of the processing operation. The applicant agrees to comply with the requirements of Article 20-C.

Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application, may be punishable

under the provisions of Section 210.45 of the Penal Law of the State of New York.

(9) ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER

TITLE

DATE

AUTHORIZATION AND PURPOSE

Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State

Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been

delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the

Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law.

The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific

license you are seeking. This information is collected to enable the Department to evaluate your application, to determine if it should be issued and to

assist in the enforcement and administration of the Agriculture and Markets Law.

All fields must be completed. Incomplete applications may not be processed. If you have questions about

the information requested, call (518) 485-5326; or write to: NYS Department of Agriculture and Markets; Attn:

Licensing Unit; 10B Airline Drive; Albany, NY 12235.

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FSI – LICENSING UNIT

PHONE: 518-485-5326

One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize the NYS Department of Agriculture and Markets to make a one-

time charge to your credit card listed below. Please mail to the below address.

By signing this form you give us permission to charge your account for the amount indicated on or after

the indicated date. This is permission for a single transaction only, and does not provide authorization for

any additional unrelated charges or credits to your account.

Please complete the information below:

I _________________________________, authorize the NYS Department of Agriculture and Markets to charge my

credit card account indicated below for $400.00. This payment is for a:

FOOD PROCESSING LICENSE

Billing Address ________________________________ Phone# ________________________

City _________________________________________ State _______ Zip ________

Email ____________________________________________________________________________

Account Type: Visa MasterCard AMEX Discover

Cardholder Name _____________________________________________

Account Number _____________________________________________

Expiration Date _______________

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)_______

FOR OFFICE USE ONLY

Estab No.:_________

License No.:____

Receipt No._______________

Validation No._____________

SIGNATURE DATE

I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization form according to the terms outlined

above. This payment authorization is for a Food Processing License, for the amount indicated above only, and is valid for one time use only. I certify that

I am an authorized user of this credit card.