Proposes Details

Dbpr Form Hr 5021 103 is a form used by the Department of Business and Professions Regulation in the State of Florida to report any disciplinary action taken against a professional. Any individual or entity licensed, certified, or registered by DBPR must complete and submit this form within 14 days of taking disciplinary action. The penalties for not reporting can be significant, so it is important to understand how and when to use this form correctly. This blog post will provide an overview of Dbpr Form Hr 5021 103 and explain who needs to file it.

This quick guide will aid you to determine how much time it will require you to fill out dbpr form hr 5021 103, the number of pages it's got, and some other specific specifics of the PDF.

QuestionAnswer
Form NameDbpr Form Hr 5021 103
Form Length1 pages
Fillable?Yes
Fillable fields58
Avg. time to fill out11 min 51 sec
Other names

Form Preview Example

State of Florida

Department of Business and Professional Regulation

Division of Hotels and Restaurants

SEATING CHANGE EVALUATION

Completion of this form ensures that public food service establishments are evaluated for adequate sewage and fire services before expanding seating operations. Submit the completed form to the local Division of Hotels and Restaurants district office.

SECTION 1 – ESTABLISHMENT INFORMATION

Establishment Name:

License Number: Current No. Seats: Proposed No. Seats:

Address of Establishment:

Contact Person Name / Phone No.:

City:

County:

Zip:

Contact Person E-Mail Address:

SECTION 2 – WASTEWATER SYSTEM

(To Be Completed By DOH, DEP or Utility Authority)

The above named food service establishment uses the following wastewater disposal system (choose one type):

Municipal / Utility

Name of Provider:

 

 

Grease Trap Required

Location

 

 

 

 

 

Yes

No

In-ground

Undersink

 

 

 

 

Package Plant

Name of Provider:

 

 

Grease Trap Required

Location

 

 

 

 

 

Yes

No

In-ground

Undersink

 

 

 

 

Septic Tank

Permit #:

 

Tank Size:

Drainfield Size:

 

Grease Trap Size:

System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM EVALUATION RESULT:

 

 

 

 

 

 

Permit Issued

Final Approval

Denied (see comments)

 

 

 

 

 

 

 

 

 

 

LIMITATIONS ON SYSTEM

 

Comments:

 

 

 

 

 

Single-Service Only

Other Conditions

 

 

 

 

 

 

 

Maximum Number of Hours of Operation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maximum Number of Seats Permitted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Menu Restricted (see comments)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name & Title

Agency

Signature

Date

Address

Phone

SECTION 3 – FIRE SAFETY

(To Be Completed By Local Authority Having Jurisdiction)

The above named food service establishment proposes to increase the seating capacity

Number of Exits

Public:

Employee:

Total:

FIRE SAFETY EVALUATION RESULT:

Approved

Denied (see comments)

Comments:

Name & Title

Agency

Signature

Date

Address

Phone

H&R Change Record Form Attached

DBPR Form HR 5021-103

www.MyFloridaLicense.com/dbpr/hr 61C-1.002, FAC

2008 October 22

How to Edit Dbpr Form Hr 5021 103

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Step 1: The first step should be to choose the orange "Get Form Now" button.

Step 2: Now, you're on the form editing page. You may add information, edit present data, highlight specific words or phrases, put crosses or checks, insert images, sign the document, erase unrequired fields, etc.

The PDF document you plan to fill in will consist of the following segments:

step 1 to filling out ensures

In the section LIMITATIONS ON SYSTEM, Comments:, Single-Service Only, Other Conditions, Maximum Number of Hours of, Maximum Number of Seats Permitted, Menu Restricted (see comments), Name & Title Signature Address, Agency Date Phone, SECTION 3 – FIRE SAFETY, (To Be Completed By Local, The above named food service, Number of Exits, Public:, Employee:, and Total: enter the data that the application requests you to do.

ensures LIMITATIONS ON SYSTEM, Comments:, Single-Service Only, Other Conditions, Maximum Number of Hours of, Maximum Number of Seats Permitted, Menu Restricted (see comments), Name & Title Signature Address, Agency Date Phone, SECTION 3 – FIRE SAFETY, (To Be Completed By Local, The above named food service, Number of Exits, Public:, Employee:, and Total: blanks to fill

Within the field talking about Approved, Denied (see comments), FIRE SAFETY EVALUATION RESULT:, Comments:, Name & Title Signature Address, H&R Change Record Form Attached, Agency Date Phone, DBPR Form HR 5021-103, www, and 61C-1, make sure you type in some essential data.

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