3915 Form – Fill Out and Use This PDF

NEW YORK STATE DEPARTMENT OF HEALTH Application for a Permit to Operate Bureau of Community Environmental Health and Food Protection

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.

F.Tanning Facility: enter the total number of tanning devices.

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.

Facility Types:

Agricultural Fairgrounds	Mass Gathering	Temporary Residences
Bathing Beaches	Migrant Farm Worker Housing	Labor Camps other than Migrant
Freshwater River	Farm Labor Housing	Interior Corridor – Single Story
Impoundment/Pond	Mobile Home Parks	Interior Corridor – Two Story
Lake	Mobile Food	Interior Corridor – Three Story
Ocean Surf	Recreational Aquatic Spray Grounds	Interior Corridor – Four or more Story
Other Saltwater	Indoor	Exterior Corridor – Single Story
Campground/Recreational Vehicle Park	Outdoor	Exterior Corridor – Two Story
Children’s Camps	Swimming Pools	Exterior Corridor – Three Story
Day Camp	Indoor	Exterior Corridor – Four or more Story
Day Camp – Developmentally Disabled	Outdoor	Cabin or Bungalow Colony
Day Camp – Municipal	Indoor/Outdoor	Vending Food Machines
Day Camp – Traveling	Wave Pool – Indoor	State Agency Licensed Facilities
Overnight Camp	Wave Pool – Outdoor	State Licensed Inspected Facility
Overnight Camp – Developmentally Disabled	Wave Pool – Indoor/Outdoor	State Owned Operated Facility
Overnight Camp - Municipal	Aquatic Amusement – Indoor	Day Care Center – Residential
Food Service Establishment	Aquatic Amusement – Outdoor	Day Care Center – Non-Residential
Restaurant	Aquatic Amusement – Indoor/Outdoor
Caterer	Spa
School	Tanning Facility
Institution	Temporary Food
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

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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 (i.e.: 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. For tanning facilities enter the number of beds and booths. Some facilities with multiple operations require separate applications, (i.e., 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 (i.e., 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 AM or PM 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 Employer Identification or Social Security Number of the operator of the

facility.

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 the 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 the operator.

SECTION C: Complete only for temporary food service establishments, regulated under Subpart 14-2 NYSSC

SECTION D: Complete only for mobile food service vehicles or pushcarts, regulated under Subpart 14-4 NYSSC

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 Subpart 14-5 NYSSC

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

Provide copies of appropriate forms documenting compliance with the Worker's Compensation Law for (1) both Workers' Compensation and New York State Disability Insurance coverage, or (2) exemption from coverage.

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.

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Complete all items that apply to your establishment (all applicants must

complete Sections A, B, G and H), sign on the back page and return

with the appropriate fee at least 30 days prior to the expected opening date to:

SECTION A: Facility Information (Entire section must be completed by all applicants.)

Water Supply Sewage System Number of operations under this registration

[__] Public (municipal) [__] Public (municipal) [___] Indoor Pools [___] Bathing Beaches [___] Food Services [___] Day Camps

[__] Private (onsite) [__] Private (onsite) [___] Outdoor Pools [___] Spa Pools [___] Recreational Aquatic Spray Grounds

[___] Tanning Devices

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 ___________________________________ Telephone no. (___)_______________ Fax no. (___)_______________

Permanent address _________________________________________ Email address _____________________________________

City ________________ State ______ Zip ________ Employee Identification Number [___] [___] [___][___][___][___][___][___][___]

Or Social Security Number [___][___][___]-[___][___]-[___][___][___][___]

Owner _____________________________ Telephone (___)________________

Permanent address ______________________________________ City ______________________ State ______ Zip ____________

SECTION C: Complete for temporary food service establishments only (attach additional sheets as necessary).

Name and location of event ______________________________________________________________________________________

Name of Foods Supplier of ingredients Where and how foods will be prepared and served

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SECTION D: Complete for mobile food service establishments or pushcarts only.

Type of vehicle [__] Motorized [__] Pushcart [__] Other (specify) _____________________________________________________

Motor vehicle license number (motorized vehicles only) ______________________________________________________________

Commissary name _________________________________________________________ Telephone No. (___) ________________

Address ____________________________________________ City ____________________ ___ State ______ Zip _____________

List on a separate sheet of paper the type 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 lines and submit copies of the following documentation with the application to document compliance with the

Worker's Compensation Law:

A.Workers Compensation and Disability Insurance Coverage Provided Workers Compensation

[__] Form C-105.2 – Certificate of Worker's Compensation Insurance OR

[__] Form U-26.3 – Certificate of Workers' Compensation Insurance OR

[__] FormSI-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 NOT Provided

[__] Form CE-200 – Certificate of Attestation of Exemption from NYS Workers’ Compensation and/or Disability Benefits Coverage

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 ___________

Section I: FOR OFFICE USE ONLY

SECTION I: FOR OFFICE USE ONLY

Permit issuance recommended? [__] Yes [__] No Permit Effective Date [___][___][___] Permit Expiration Date [___][___][___] Conditions of approval

Signature ______________________________________________ Title _________________________ Date ________________

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