APPLICATION FOR FOOD FACILITY
COMPLETE ONE APPLICATION
IN FULL FOR EACH TYPE OF SERVICE IN YOUR FACILITY -PLEASE PRINT WHERE POSSIBLE
The personal information collected relates directly to and is necessary for program operation per Section 26 of the Freedom o
f Information and Protection of Privacy Act. Information that
appears on a licence may be disclosed per Section 22(4)(i) of the Ac
t, as it is not considered an unreasonable invasion of personal privacy.
RETURN FORM TO NEAREST HPES OFFICE
: https://www.islandhealth.ca/our-locations/health-protection-environmental-services-locations
Health Protection &
Environmental Services
STATUS
NEW
New Facility
New Location
New Ownership
Change to Facility
FOOD
FACILITY
FACILITY NAME_________________________________________________________________________________________________
FACILITY LOCATION ADDRESS_____________________________________________________________________________________________________
CITY____________________________________________________________________POSTAL CODE___________________________________________
TELEPHONE_____________________________FAX____________________________EMAIL___________________________________________________
MAILING ADDRESS IF DIFFERENT FROM ABOVE_______________________________________________________________________________________
SEND INVOICE TO SAME AS FACILITY SAME AS MAILING OR:___________________________________________________________________
FACILITY’S
REGISTERED
OWNER(S)
OR
LEASEE(S)
REGISTERED OWNER/LEASEE NAME_______________________________________________________________________
MAILING ADDRESS_______________________________________________________________________________________
CITY________________________________PROV_________________________________POSTAL CODE__________________
TELEPHONE____________________________ FAX_______________________ ALTERNATE PHONE_____________________
EMAIL ______________________________________________________________________________________
SOCIETY
SOLE PROPRIETOR
PARTNERSHIP
INCORPORATED
FACILITY
MANAGER /
CONTACT
CONTACT NAME________________________________________________________________________________POSITION________________________
ADDRESS_______________________________________________________________POSTAL CODE___________________________________________
TELEPHONE_____________________________FAX_____________________________EMAIL__________________________________________________
BUILDING
INFORMATION
IF THE FACILITY IS PART OF A MALL, NAME OF MALL___________________________________________________________________________________
BUILDING NAME (IF DIFFERENT FROM FACILITY) _____________________________________________________________________________________
ADDRESS____________________________________________________________CITY_____________________________POSTAL CODE_____________
OWNER OF
BUILDING OR
COMPLEX
REGISTERED NAME______________________________________________________________________________________
MAILING ADDRESS_______________________________________________________________________________________
CITY____________________________________________PROV_____________________POSTAL CODE_________________
CONTACT/AGENT NAME ______________________________________________________POSITION_____________________
TELEPHONE_____________________________FAX_______________________________EMAIL________________________
SOCIETY
SOLE PROPRIETOR
PARTNERSHIP
INCORPORATED
FACILITY
SERVICING
WATER SOURCE COMMUNITY (SYSTEM NAME)______________________________________________ WELL OTHER SPECIFY
SEWAGE DISPOSAL SEWER ONSITE SEWAGE DISPOSAL
OPERATIONAL
MONTHS
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
ALL YEAR
WILL YOUR OPERATION PREPARE FOOD/DRINK ON SITE FOR IMMEDIATE CONSUMPTION?
YES
NO
WILL YOUR OPERATION PREPARE FOOD OFF SITE?
YES IF “YES” LOCATION ______________________________
NO
WILL YOUR OPERATION PROVIDE SEATING FOR CONSUMPTION OF PREPARED FOOD?
YES IF “YES” TOTAL SEATING CAPACITY ______________
NO
WILL YOUR OPERATION BE MOBILE?
YES IF “YES” TYPE CART VEHICLE VESSEL
NO
WHAT TYPE OF FOOD PREMISES WILL YOU BE OPERATING?
RESTAURANT
TAKE OUT
MOBILE
CONCESSION
STORE
FISH PROCESSOR LOUNGE/BAR CARE FACILITY KITCHEN
CATERER OTHER_______SPECIFY___________
WILL THE FACILITY BE RENTED OR LEASED TO OTHERS?
YES IF “YES” ENSURE THEY HAVE CONTACTED OUR OFFICE
FOR NECESSARY APPROVAL
NO
WILL YOUR OPERATION CONDUCT BUSINESS MORE THAN 14 DAYS IN A 12 MONTH PERIOD
YES
NO
WILL YOUR OPERATION SELL TOBACCO PRODUCTS?
YES IF “YES” VENDING MACHINE OVER THE COUNTER
NO
WILL YOUR OPERATION PROVIDE AN OUTSIDE SMOKING AREA?
YES
NO
VERIFICATION
APPLICANT SIGNATURE__________________________________________________________________
I hereby certify that the information set out by me in this application is true and correct to the best of my knowledge and belief.
I acknowledge that it is an offence to supply false or inaccurate information on this application.
PRINT NAME_____________________________________________________POSITION______________
PHONE___________________ ADDRESS___________________________________________________
DATE_______DD / MMM / YYYY
______________________________________
PROPOSED OPENING DATE
PLANS INCLUDED YES NO
FOR
OFFICIAL
USE ONLY
DATE
INITIALS
APPLICATION PACKAGE REC’D
FACILITY TYPE
PLANS APPROVED BY EHO
FACILITY #
FACILITY APPROVED BY EHO
AMOUNT PAID
POSTED TO HEALTHSPACE
METHOD OF PAYMENT
OPERATING PERMIT SENT
RECEIPT #
H:\FOOD\FORMS\APPLICATION FOR FOOD FACILITY June 2019 WHITE COPY HEALTH AUTHORITY YELLOW COPY APPLICANT PINK COPY - TOBACCO
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