Fillable Form 2021: FILL OUT FORM COMPLETELY (Starke County Indiana)

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Form 2021: FILL OUT FORM COMPLETELY (Starke County Indiana)

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Starke County Health Department
108 N Pearl St
Knox, IN 46534
Ph. (574) 772-9137
FILL OUT FORM COMPLETELY
2021
APPLICATION to OPERATE a RETAIL FOOD ESTABLISHMENT as defined in:
TITLE 410 IAC 7-24. **All 2020 permits expire 12-31-20**
Name of Establishment: __________________________________________________
Address of Establishment: ________________________________________________
Mailing Address of Establishment: _________________________________________
Phone#: _____________ FAX#: ______________ e mail: ________________________
Legal Owner of Establishment:_____________________________________________
Legal Owner Address: ___________________________________________________
Operator of Establishment:________________________________________________
Certified Food Handler employed at facility as mandated by 410 I.A.C. 7-22
Name of employee:___________________________________
Type of Certification (these are the only three accredited by Indiana):
___ ServSafe ___Certified Professional Food Manager ___ Food Safety Mgr. Certif.
Certification # on certificate: _______________________________________
Type of operation: ___ Restaurant ___ Full Service Grocery ___ Convenient Store
___Other: ______________________________________
All operations must comply with the Indiana Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24. Any
renovation, remodeling, or change of operations in a food establishment must be approved by the Starke County Health
Department. NO FOOD ESTABLISHMENTS ARE ALLOWED TO OPERATE WITHOUT A VALID CURRENT PERMIT.
SIGNATURE: ______________________________________ ____________________________________
(WRITTEN) (PRINTED)
TITLE: ____________________________________ DATE: _______________________
THE 2021 PERMIT FEE IS: HIGH RISK $100.00
MENU TYPES 2-5
LOW RISK $70.00
MENU TYPE 1
Risk assessment based on menu type. See reverse side for Menu Type.
PERMITS CANNOT BE SOLD, ASSIGNED, LOANED or TRANSFERRED
Complete this form and mail to the address at the top of the page by 12-31-2020
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MENU TYPE
1. Pre-packaged non-potentially hazardous foods. Limited preparation of non-potentially hazardous foods.
2. Pre-packaged raw ingredients are cooked or prepared to order. Retail food operations exclude deli or
seafood departments. Raw ingredients require minimal assembly. Most products are cooked/prepared to
order and served immediately. Hot and cold holding of potentially hazardous foods is restricted to single
meal service. Preparation processes requiring cooking, cooling, and reheating are limited to 1 or 2
potentially hazardous foods.
3. Extensive handling of raw ingredients. Preparation process includes the cooking, cooling, and reheating
of potentially hazardous foods. A variety of processes require hot and cold holding of potentially
hazardous food. Advanced preparation for next day service is limited to 2 or 3 items. Retail food
operations include deli and seafood departments.
4. Extensive handling of raw ingredients. Preparation process includes the cooking, cooling, and reheating
of potentially hazardous foods. A variety of processes require hot and cold holding of potentially
hazardous food. Food processes include advanced preparation for next day service. Category would also
include those facilities whose service population is highly susceptible.
5. Extensive handling of raw ingredients. Food processing at the retail level, e.g. smoking and curing;
reduced oxygen packaging for extended shelf life.
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Form 2021: FILL OUT FORM COMPLETELY (Starke County Indiana)

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Completed 12 August 2021

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