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NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection DOH-3915 (3/09) p. 1 of 4 GENERAL INSTRUCTIONS Complete all items that apply to your establishment. All applicants must complete sections A,B,G,& H. If you have any questions, contact the local health department that issues your permit. SECTION A: Facility Information Facility Name, Facility Address, Telephone Number, Fax Number and Municipality: Self explanatory Capacity A. Food services: enter actual seating capacity, or enter 00 for take out only. B. Recreational vehicle parks, campsites, agricultural fairgrounds and mobile home parks: enter the number of actual sites. C. Children’s camp: enter the maximum number of campers the camp is approved for at one time. D. Temporary residences and migrant farmworker labor camps, swimming pools, bathing beaches, mass gatherings: enter the maximum number of people the facility is approved to hold. E. Recreational aquatic spray ground: enter 00. Facility Status: Check either profit or nonprofit. If nonprofit, submission of documentation (incorporation paper) verifying status may be required. Facility Type: From the list below enter the facility type that best describes the main or primary operation of the facility. Some multiple operation facilities may require submission of separate permit application(s). Please consult the health department that issues your permit with any questions. Application for a Permit to Operate Facility Types Agricultural Fairgrounds Bathing Beaches Freshwater River Impoundment/Pond Lake Ocean Surf Other Saltwater Campground/Recreational Vehicle Park Children’s Camps Day Camp Day Camp – Developmentally Disabled Day Camp – Municipal Day Camp – Traveling Overnight Camp Overnight Camp – Developmentally Disabled Overnight Camp – Municipal Mass Gathering Migrant Farm Worker Housing Farm Labor Housing Mobile Home Parks Recreational Aquatic Spray Grounds Indoor Outdoor Swimming Pools Indoor Outdoor Indoor/Outdoor Wave Pool – Indoor Wave Pool – Outdoor Wave Pool – Indoor/Outdoor Aquatic Amusement – Indoor Aquatic Amusement – Outdoor Aquatic Amusement – Indoor/ Outdoor Spa Temporary Residences Labor Camps other than Migrant Interior Corridor – Single Story Interior Corridor – Two Story Interior Corridor – Three Story Interior Corridor – Four or more Story Exterior Corridor – Single Story Exterior Corridor – Two Story Exterior Corridor – Three Story Exterior Corridor – Four or more Story Cabin or Bungalow Colony Food Service Establishment Restaurant Caterer School Institution State Office for the Aging (SOFA) – Prep Site State Office for the Aging (SOFA) – Satellite Site Summer Feeding Program (USDA) – Prep Site Summer Feeding Program (USDA) – Satellite Site Temporary Food Mobile Food Vending Food Machines State Agency Licensed Facilities State Licensed Inspected Facility State Owned Operated Facility Day Care Center – Residential Day Care Center – Non-Residential ---PAGE BREAK--- DOH-3915 (3/09) p. 2 of 4 Water Supply/Sewage System: Check “public” if the facility is serviced by a municipal or public system. Check “private” (onsite) if the system(s) and its operation is onsite and only for this facility. A water/sewage system that is commonly used by several establishments a mall operation) would be a public system. Operations under this registration: Provide the number of specific operations that apply to this registration. Complete even if the primary or main operation of the facility was identified under the facility type. A swimming complex with one spa, one beach, one indoor and two outdoor pools would report a facility type swimming pool-indoor and enter 1 for spa, 1 for bathing beach, 1 for indoor pool and 2 for outdoor pools in the operations under this registration Section A. Some facilities with multiple operations require separate applications, a food service operated at a swimming pool complex would require a separate swimming pool and food service application, and would report their specific operations on the appropriate application forms). Expected Opening/Closing Date: Enter the expected opening and closing dates June 1 is 06/01). If the operation is year-round, enter 01/01 for opening and 12/31 for closing. Days of Operation: Check each box for the day(s) the facility will be open under routine operation. Hours of Operation: Enter the hour the facility is expected to open and close under routine operation. Circle A.M. or P.M. as appropriate. SECTION B: Operator/Owner Information Name of Legal Operator or Operating Corporation (Person in Charge) Enter name of the legal entity that operates the facility. If the facility is operated by a corporation, enter the name of the operating corporation and the name of the person in charge of the day to day operation. Provide the name(s) of the corporate officers/partners in Section F. Permanent Address of Operator and Telephone Number Enter the mailing address including street, city, state and zip code where the legal operator wants to receive mailed correspondence. Enter the telephone and fax number of the legal operator. Employer Identification/Social Security Number Enter the name of the owner of facility if different from the operator. Email Address and Fax No. Enter the email address and fax no. where important health and safety alert messages should be sent during an emergency. Name of Owner Enter the name of the owner of facility if different from the operator. Permanent Address of Owner and Telephone Number Enter the mailing address and telephone number of the owner if different from operator. SECTION C: Complete only for temporary food service establishments, regulated under Subpart 14-2 SECTION D: Complete only for mobile food service vehicles or pushcarts, regulated under Subpart 14-4 Check the appropriate type of unit. If motorized, provide the license plate number. Provide the name and address of the commissary where the food is prepared. Attach a separate list of the types of food(s) and/or beverages to be served. SECTION E: Complete only for food/beverage vending machines regulated under Supbart 14-5 Attach a list of the number and type of food dispensing machines including the address and telephone number of each site under this permit. SECTION F: Partners and Corporation Officers If a facility is operated by a partnership or corporation, provide the name, title, permanent mailing address and telephone number of all corporate officers or partners involved in the operation or ownership of the facility. SECTION G: Workers’ Compensation and Disability Insurance Check the appropriate box(s) and submit a copy of the form(s) with this application to demonstrate compliance with the Workers’ Compensation Law. SECTION H: Signature Provide the signature of the individual operator, a corporate officer or other authorized identified official in Section F. Please print the name, title and date in the space provided. Failure to sign the form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code and is punishable by fines. SECTION I: To be completed by the local health department ---PAGE BREAK--- ( ) ( ) Section A: Facility Information (Entire section must be completed by all applicants.) Facility name Facility address City State Zip Telephone no. Fax no. Municipality T V C Capacity Facility Status Profit Non-profit Facility Type Water Supply Sewage System Number of operation(s) under this registration Public (municipal) Public (municipal) Indoor Pools Bathing Beaches Private (onsite) Private (onsite) Outdoor Pools Food Service Spa Pools Frozen Dessert Day Camps Recreational Aquatic Spray Grounds Indicate days of operation by checking the appropriate boxes. Expected Expected Hours of AM AM opening date closing date S M T W T F S operation PM PM Month/Day Month/Day Open Close Complete all items that apply to your establishment (all applicants must complete Sections A, B, G and sign on the back page and return to the local health department. DOH-3915 (3/09) p. 3 of 4 ( ) Section B: Operator/Owner Information (Entire section must be completed by all applicants.) Legal operator or operating corporation (If corporation or partnership, Section F must be completed.) Person in charge Permanent address City State Zip Telephone no. Email address Fax no. Employer Identification Number OR Social Security Number - - Owner Permanent address City State Zip Telephone no. Section C: Complete for temporary food service establishments only (attach additional sheets as necessary). Name and location of event Name of food Supplier of ingredients Where and how foods will be prepared and served ( ) ( ) Application for a Permit to Operate ---PAGE BREAK--- ( ) Section D: Complete for mobile food service establishments or pushcarts only. Type of Vehicle Motorized Pushcart Other (specify) Motor vehicle license no. (for motorized vehicles) Commissary name Address City State Zip Telephone no. List on separate sheet types of food and beverages served. Section E: Food and beverage machines only. Attach a list of all machine locations and food dispensed. Section F: Partners and Corporate Officers List all partners and corporate officers in the operation of the facility. Include vice president(s), secretary, treasurer. Attach DOH-2135 (or additional sheets) as necessary. Name Title Address Telephone No. ( ) ( ) ( ) ( ) Section G: Workers’ Compensation and Disability Insurance (All applicants must complete this section). Check the appropriate box(s) and submit a copy of the form(s) with this application to demonstrate compliance with the Workers’ Compensation Law. A. Workers’ Compensation and Disability Insurance Coverage Provided Workers' Compensation Form C-105.2 Certificate of Workers' Compensation Insurance OR Form U-26.3 Certificate of Workers' Compensation Insurance OR Form SI-12 Certificate of Workers' Compensation Self-Insurance OR GSI-105.2 Certificate of Participation in Workers' Compensation Group Self-Insurance AND Disability Insurance DB-120.1 Certificate of Disability Benefits OR Form DB-155 Certificate of Disability Benefits Self-Insurance B. Workers’ Compensation and Disability Insurance Coverage Provided NOT Provided. Form CE-200 Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage DOH-3915 (3/09) p. 4 of 4 Section I: FOR OFFICE USE ONLY Permit issuance recommended? Yes No Permit Effective Date Permit Expiration Date Conditions of approval Signature Title Date Section H: Signature (Entire section must be completed by all applicants). FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code. Signature of individual operator or authorized official Print name of person signing Title Date SIGN SIGN