Fillable Printable Food Licence Application Form - Pennsylvania
Fillable Printable Food Licence Application Form - Pennsylvania
Food Licence Application Form - Pennsylvania
CITY OF PHILADELPHIA ± DEPARTMENT OF LICENSES AND INSPECTIONS
WHEN COMPLETED MAIL TO:
License Application
FOOD
DEPARTMENT OF LICENSES AND INSPECTIONS
CUSTOMER CARE UNIT
PUBLIC SERVICE CONCOURSE
1401 JOHN F KENNEDY BLVD.
PHILADELPHIA, PA 19102
Please read instructions attached to this form.
For additional information call 311 or 215-686-8686
USE A SINGLE &+(&.25021(<25'(53$<$%/(72³&,7<2)3+,/$'(/3+,$´
LICENSEE INFORMATION
1. NAME OF LICENSEE (BUSINESS or OWNER) 2. BUSINESS NAME (IF DIFFERENT THAN NAME OF OWNER)
3. LICENSEE MAILING ADDRESS (PO Boxes Are Not Acceptable)
4. BUSINESS LOCATION
5. DAYTIME PHONE NUMBER 6. EVENING PHONE NUMBER 7. FAX NUMBER 8. E-MAIL ADDRESS
9. COMMERCIAL ACTIVITY LICENSE NUMBER 10. BUSINESS INCOME AND RECEIPTS TAX NUMBER
11.LICENSE TYPE (Check All That Apply) FEE
REVENUE
CODE
EXPIRATION
DATE
LICENSE NUMBER
ƑFood Establishment (Retail, Non-Perm.)
$150.00
3112
4/30/
ƑFood Establishment (Retail, Perm Loc, up to 5,000 Sq. Ft.
based on gross store area)
$200.00
3118
4/30/
ƑFood Establishment (Retail, Perm Loc, over 5,000 Sq. Ft.
based on gross store area)
$500.00
3119
4/30/
ƑFood Manufacturer, Wholesale Processed
$350.00
3113
4/30/
ƑFood Preparing and Serving, up to 50 seats
$300.00
3120
4/30/
ƑFood Preparing and Serving, more than 50 seats
$300.00
3121
4/30/
ƑFood Preparing and Serving, Caterer
$300.00
3122
4/30/
I certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand
that if I knowingly make false statements herein I am subject to the possible revocation of any licenses issued as a result
of my false application and such penalties as prescribed by law.
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