Free 49677.pdf - Indiana

Reset Form

REGISTRATION APPLICATION FOR A RETAIL FOOD ESTABLISHMENT
State Form 49677 (R5/11-08)
Indiana State Department of Health Food Protection Program

(a) (b) (c)

410 IAC 7-24-107 PREREQUISITE FOR OPERATION A person may not operate a retail food establishment without first having registered with the department as required under IC 16-42-1-6. A retail food establishment registered with a local health department or other regulatory authority shall be considered registered with the department under IC 16-42-1-6. To allow verification that the retail food establishment is constructed, equipped, and otherwise meets requirements of this rule, the regulatory authority shall be notified of an intent to operate at least thirty (30) days prior to registering under this rule.

Please complete all sections of this form
Owner/Lessee Name: Telephone Number: Fax Number:

O W N E R

Mailing Address: Email Address: Lessor's Name (building owner): Mailing Address: Email Address: Name of Business: Physical Location:

Telephone Number:

Telephone Number: Fax Number: Sewage Disposal: _____City _____Private Water Source: _____City _____Private; PWS #:
___________________

B U S I N E S S

Mailing Address: Operator: Mailing Address: Name of Certified Food Handler: On-Site Supervisor: Hours of Operation: Type of Business: _____Permanent _____Mobile _____Temporary Food to be Served:

Telephone Number: Email Address: Telephone Number: Days of Operation: Off-Site Catering: _____Yes _____No

Name of Temporary Event:

T E M P O R A R Y

Event Location (i.e. Building or Physical Location): Event Contact: Date(s) and Hours(s) of Operation: Location of Off-Site Prep and/or Storage Unit: Food to be Served: Telephone Number: Food Prep and/or Storage Off-Site _____Yes _____No

Return completed Form: __________________________________ Indiana State Department of Health Food Protection Program, Room 5C 2 North Meridian Street Indianapolis, IN 46204 317/233-7360
(Original Signature of Applicant)

_______________________ (Date)
_____________________________ (Title)

__________________________________________ (Printed Signature of Applicant)

For Office Use Only:

Menu Type_______

Registration Number: ___________