HEALTH PROTECTION PROGRAMS
FOOD SERVICE PERMIT
APPLICATION FORM
This form must be completed for all new facilities and for any changes to facility information (PRINT IN BLOCK LETTERS)
Facility Name: (as it will appear on permit)
Phone: ( ) _______ - __________
Fax: ( ) _______ - __________
Facility Site Address: Postal Code: _____ _____
City: _______________, BC
E-mail
:
Web
site
:
Legal (Company) Name: {Proof of incorporation may be requested} Business Licence # (if available):
Owner Legal Type: Sole Proprietor Partnership Corporation Other (define)
Owner’s Name:
Last Name First Name
Home Phone:
( ) _____ - _______
Mobile Phone: ( ) _____ - _______
Operator's Name:
Last Name First Name
Home Phone:
( ) _____ - _______
Mobile Phone: ( ) _____ - _______
Type of Change: (if change box is checked, updated info and Effective Date of change are required)
a) Facility Name change: Old Name Was: ______________________
Existing Facility # _____________________
b) Facility Address Change/ Mailing Address Change
c) Change in
Conditions on Permit
d)
Owner Change – Invoice? Ye
s No
e) Operato
r Change
f)
Facility Type/capacity change (may impact on permit fee)
g) F
acility closed (voluntarily) Date Effective _____________
Is there a secondary permit connected to this facility? Yes No
h) Other
(specify) _______________________________________
THE FOLLOWING MUST BE COMPLETED FOR OPERATING PERMIT FEE
Billing Account (for INVOICE mailing) same as facility OR:
Account Owner (Billing Contact): ______________________________
E-mail: ____________________________________________________
Address: __________________________________________________
City: _________________ Prov/State: ______Postal Code: _________
Phone: ( ) _____ - ________ Fax: ( ) _____ - ________
Mailing Address: (for NON-BILLING mailing) same as facility OR:
Address: __________________________________________________
City: ___________________ Prov/State: _______ Postal Code: ______
Phone: ( ) _____ - ________ Fax: ( ) _____ - ________
Mail
Permit Decal to: Facility Address Mailing Address
{Permit decals are mailed to Billing Account Address unless indicated differently above}
Maximum Seating Capacity: _______ seats Exempt Facility? Yes (If Yes, Exemption Request Form must be submitted with this form)
Secondary Permit? Yes IF YES, Facility # of Primary Site: ____________ (Secondary Permit only issued if under same roof and same owner)
Do you wish to have other facilities owned by you rolled up to one invoice? If so, please provide Facility #s here: _____________________________
FOR SEASONAL PREMISES, CIRCLE WHICH MONTHS YOU ARE OPERATING (Include whole and partial months)
JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC
Date of Application: ______________________________ Applicant's Signature: __________________________________
THIS BOX MUST BE COMPLETED FOR ALL NEW APPLICATIONS Applicant's Name (Print): ________________________________
Office Use Only
Is this a NEW Application or a CHANGE to facility information? NEW: CHANGE: EFFECTIVE DATE: ______/____/____ (MMM/DD/YY)
Facility Information: Permitted Facility Type (check one) Conditions on Permit:
HH Facility #: _____________________
Work Area: ____________
EHO: __________________________
Billing Account Information:
Account #: ________________________
Account Work Area: ________________
FSE1 - Food Service Establishment - Type 1
Attribute (define) __________________
FSE2 - Food Service Establishment - Type 2
Attribute (define) __________________
Mobile Food Service – Type B
Attribute (define) __________________
Mobile Food Service – Type C
Attribute (define) __________________
FoodSafe, Food Safety Plan, & Sanitation
Plan documentation to be provided within
90 Days
Restricted Cooking – no grease laden
vapours can be generated
Single Service Utensils Only
Seating restricted to 16 or less
Other ___________________________
VCH.0419 | AUG.2019
WHITE COPY - FACILITY FILE YELLOW COPY - APPLICANT
click to sign
signature
click to edit
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