Fillable APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE ARTICLE 20-C (New York State)

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APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE ARTICLE 20-C (New York State)

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FSI-303 (03/22/2021)
Office Use Only
County Code- Est. No.
Entity No. ___________________________
Receipt No. _________________________
Verification No. ______________________
APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE – ARTICLE 20-C
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
PROJECTED OPENING DATE: __ __ / __ __ / __ __
LICENSE FEES (CHECK WHERE APPROPRIATE) :
$0 No Fee $175.00 $400.00
Production in a Small-Scale Processor, is ALL OTHERS
Incubator/Shared Kitchen NOT a Chain Store/Franchise
for First-time applicant and employs NO more than
for the first Two (2) years Ten(10) Full Time Employees
NOTICE Regarding Fees
The commissioner shall waive the license fee for two years for a first-time applicant that
processes food in a kitchen incubator food processing facility, which for the purposes of
this section is a food processing facility used by multiple small and emerging food
processing businesses, including both full-time facility tenants and businesses that rent
space on a temporary basis.
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 in
spection.
(1) Individual Owner Name, Partnership (name all partners) or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
( )
Processing Facility Address
Street:
City:
State:
Zip:
E-mail Address:
(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)
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: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
INSTRUCTIONS
Read and complete both sides of this application.
An original signature of owner or corporate
officer or LLC managing member is required in
Section (8). Non-Refundable Application Fee.
Please ensure that you are applying for the
correct license.
(5) 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.
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
(6) 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 Education Program Course for each
location. A list of approved courses can be found on the Department website www.Agriculture.ny.gov under Food Safety link.
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:
________ An exemption from this requirement is requested for the following reason(s) ______________________________________________
__________________________________________________________________________________________________________
________ A copy of our Food Safety Education Program (FSEP) Certificate is enclosed with this application
(7) 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 __________________________________________________ OR Exempt from WCI
Name of Insurance Provider
(8) 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.
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.
NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that the 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.
**PLEASE ENSURE ALL QUESTIONS AND FIELDS ARE ANSWERED/COMPLETED BEFORE PROCEEDING**
Any unanswered questions will result in the denial of your application which PROHIBITS you from operating your business in the State of New York. If
your application is denied you must complete and re-submit your application again. Your original application and check will be returned. Please allow
60 days for application processing and once received post your license in a conspicuous place.
Providing your signature below acknowledges your understanding of requirements listed herein and that you agree to comply with the requirements of
Article 20-C.
ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER
TITLE
DATE
AUTHORIZATION AND PURPOSE
Disclosure of your 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:
NYS Department of Agriculture and Markets; Attn: Food Safety License Unit; 10B Airline Drive; Albany, NY 12235.
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One Time Credit Card Payment Authorization Form
Not to Be Completed by Those Processors Listed as Fee Exempt on Page 1 of the
APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE – ARTICLE 20-C
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 address below.
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 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 in the amount of:
$175.00 Small-Scale Processor OR $400.00 Food Processor
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.:
_________________
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.
*** Non Refundable Application Fee***
Please be sure you are applying for the correct license.
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APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE ARTICLE 20-C (New York State)

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Completed 27 October 2021

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