Application Fee is $50 - Waterbury, CT

WATERBURY HEALTH DEPARTMENT

ENVIRONMENTAL HEALTH DIVISION

Food Service Establishment License Application

Permit Status:

New ________

Renewal ________

Establishment Name: _____________________________________________________________

Address: _______________________________________________________________________

Phone Number: __________________________________________________________________

Fax Number: ____________________________________________________________________

Email Address: __________________________________________________________________

Vehicle Reg. No. (Mobile Vendors): _________________________________________________

Owner¡¯s Name: __________________________________________________________________

Address: _______________________________________________________________________

Phone Number: __________________________________________________________________

Qualified Food Operator¡¯s Name: ___________________________________________________

Application Fee is $50.00

Annual Permit Fees:

Self-Contained Trucks, Vans or Carts Vending Food

Restaurants

Group Homes/Residential Care Food Service Permit

Temporary Food Vending Establishments

Stores Including Supermarkets and Grocery Stores:

Up to 1500 Square Feet

1501 to 2999 Square Feet

3000 Square Feet and Over

$100.00

$100.00

$100.00

$ 50.00

$150.00

$ 300.00

$ 750.00

(For Mobile Vendors, please fill out separate form and submit additional fee per vehicle)

MAKE CHECKS OR MONEY ORDERS (NO CASH) PAYABLE TO: Waterbury Health Department

Application Date: _________________________ Applicant¡¯s Signature¡¯s _________________________

Office Use

Date App. Fee Paid: _____________ Check or MO # ________________________ Initials: ___________

Date Permit Fee Paid: _________________ Check or MO # ______________________Initials: _________

Date Issued: ________________________________

One Jefferson Square 3rd Floor Waterbury, CT. 06706 ¨C (203) 346.3903- Fax (203) 346.2644

C:\Users\bwatts\Desktop\Tammie\Food Service Application.doc

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