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Food Service Application
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SF-5 Application for Food Service Permit
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* Indicates required question
ESTABLISHMENT INFORMATION
Establishment Name
*
This is the Establishment Name that will be listed on your permit
Your answer
Establishment Location or Address
*
Your answer
Phone Number of Establishment and/or Food Service Manager
Your answer
Email Address(es) for Food Service Questions/Concerns
*
Your answer
Months, Days, & Hours of Operation
*
Your answer
Select Type Establishment
*
Choose
Restaurant
Retail Food Store
Retail Store with Deli, Produce, Meat, Bakery, etc.
Institution (Child Care, Hospital, Nursing Home, School, etc.)
Bar or Tavern
Vending Machine(s)
Food Bank or Food Pantry
Seating Capacity or Checkout Lanes
*
Seating available to the public during normal business hours, number of checkouts
Your answer
Estimated Number of Meals Per Day
*
Your answer
Do you serve a highly susceptible population?
*
Examples: child cares, hospitals, nursing homes, etc.
Yes
No
Required
Type Operation
*
No foods requiring cooking, cooling, reheating, hot & cold holding, raw ingredient prep
Limited cooking, cooling, reheating, hot & cold holding, raw ingredient prep
Extensive cooking, cooling, reheating, hot & cold holding, raw ingredient prep
PERMIT HOLDER and BILLING INFORMATION
Name of Owner or Permit Holder
*
Your answer
18 Years of Age or Older
*
Yes
No
Required
Phone Number of Owner or Billing Contact
*
Your answer
Owner or Billing Address
*
Your answer
Owner or Billing Email
*
For billing questions or concerns
Your answer
OWNER INFORMATION
*
Type of Ownership
Individual
Association
Corporation
Partnership
Other:
Required
PERSON-IN-CHARGE INFORMATION
*
Manager Names, Contact Information
Same as Owner/Billing Contact
Other:
Required
MENU
*
Please provide your menu one of the following ways:
Enter a link to your online menu below
List your menu items below
Email menu to
: jessica.r.shreve@wv.gov
Fax to:
304-765-2020 (include establishment name)
Mail or Hand Deliver to
:
Braxton County Health Department
617 Old Turnpike Road
Sutton, WV 26601
Your answer
Signature
*
Checking the box below signifies that you agree to the below terms
I certify that the above information is accurate. Further, I agree to comply with Legislative rule 64 CSR 17, Food Establishments, and to allow the regulatory authority access to the establishment and to records as specified under that rule.
Required
Printed Name of Signatory, Title
Please print the name of the person signing above
Your answer
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