Fillable APPLICATION FEE $250.00 License Expiration: Two years from (New York State)

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APPLICATION FEE $250.00 License Expiration: Two years from (New York State)

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FSI 302
(3/2021)
APPLICATION FOR RETAIL FOOD STORE LICENSE – ARTICLE 28-A
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
APPLICATION FEE $250.00
Non-Refundable Application Fee.
Please ensure that you are applying for the correct license.
License Expiration: Two years from date of issuance.
INSTRUCTIONS
Read and complete both sides of this application. Prepare a separate
application for each location.
An original signature of owner or corporate officer is required in Section (7).
NOTE: This license is ONLY for retail food stores that do not conduct any type of food processing operations (e.g., prepare sandwiches, cook
food on premises). If you conduct food processing operations, you must file a Food Processing Application. Inspections are scheduled after
applications are received and reviewed.
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
( )
Street:
City:
State:
Zip:
E-Mail:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification 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
Date of Birth
(4a.) Principal Office Address:
(4b.) In what state incorporated? (4c.) Date of Incorporation
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One) Yes No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State?
(4f.) If out-of-New-York-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:
Office Use Only
County Code- Est. No.
Entity No.
Receipt
No.
Verification
No.
Federal ID Number OR Social Security Number
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.
If you have questions about the information requested, call (518) 457-7139; e-mail agr.sm.foodlicense@agriculture.ny.gov;
or write to: Department of Agriculture and Markets; Attn: Food Safety License Unit, 10B Airline Drive, Albany, NY 12235.
(5) You are REQUIRED to be licensed if you offer for sale potentially hazardous food which can include any of the following: milk, shell eggs,
refrigerated meats and dairy products. List all of the foods to be covered by this license at the location listed on the front of this application.
(6) 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
Name of Insurance Provider
Self Insured
Exempt from WCI
(7) The undersigned applies for a license to operate a retail food store at this location only, pursuant to Article 28 of the Agriculture and Markets Law of
the State of New York and, in support of this application, makes the above statements and agrees to comply with the requirements of Article 28.
The applicant represents that adequate physical facilities, equipment, sanitary controls, records and practices exist to maintain the establishment in a
clean and sanitary condition and that the cleaning, maintenance and operation of the establishment is such that products handled therein will not be
adulterated.
The issuance of a license is based upon continued compliance with all requirements associated with operating a Retail Food Store.
Applicant consents to free entry and will permit free access to the licensed premises, buildings and offices to the Commissioner, the Commissioner’s
agents and inspectors in pursuance of the Commissioner’s duty to supervise and regulate storage, sale and use of articles subject to the Commissioner’s
jurisdiction.
NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that this applicant, licensee, officer, director,
partner or share/stockholder, has been convicted of, or has pled guilty to, a felony in any court of the United States or any State or territory thereof, with
respect to an offense involving, food safety, food adulteration or food misbranding.
Applicant understands the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.
In addition to being a basis for denial or revocation of license, any false statements made herein are punishable pursuant to Section 210.45 of the Penal
Law of the State of New York.
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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 debit to your
credit card listed below. Please mail to the below address.
By signing this form you give us permission to debit 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 debits 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 $250.00. This payment is for a:
RETAIL FOOD STORE 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.:
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 Retail Food Store 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.
*** Non Refundable Application Fee***
Please be sure you are applying for the correct license.
Division of Food Safety & Inspection │ 10B Airline Dr. Albany, N.Y., 12235 │ (518) 457-7139 │ www.agriculture.ny.gov
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APPLICATION FEE $250.00 License Expiration: Two years from (New York State)

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Completed 7 June 2022

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