Application for Food Facility Permit
N
ame of Facility
Physical Address
City State Zip
Mailing Address (if different from physical address) Facility Phone Number PH Priority
City State Zip
Facility Manager Name Email Fax #
Owner is (check[
3
] one): q Association q Corporation q Individual q Partnership q Other ____________________
Owner Name Owner/Designee Designee/Contact Info
Address Phone Number/Cell
Corporate Supervisor (if applicable)
Address Phone Number
Smoke Free q Yes q No
Applicant Name/Signature Date
Address Email Phone Number
For Health Department Use Only
Application Approved Date _______________________________________ Signature _____________________________
Facility is (check [
3
] one): q New q Remodel q Conversion
Plan Review Approved Date ______________________________________ Signature _____________________________
Mississippi State Department of Health Revised 2/27/18 Form No. 297
I am aware that the Mississippi State Department of Health
adopts U.S. Food and Drug Administration Food Safety Rules
with some additional regulations and I am familiar with all
applicable sections. I have complied with all requirements
of this regulation. As owner/manager of the above facility,
I hereby request the Mississippi State Department of Health
to make an inspection and to issue a permit to operate the
facility/business named above and agree that upon proper
identification a representative of the Department of Health
may enter upon these premises and into this facility/business
for the purpose of making official inspections and/or collecting
samples if applicable at any time this facility/business is open
for business. It is further understood that, should a permit be
issued, it may be suspended or revoked at any time for just
cause, as determined by the regulatory authority.
For Health Department Use Only
Facility ID Number
click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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