Dbpr Form Hr 5021 103 PDF 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?No
Fillable fields0
Avg. time to fill out15 sec
Other names5021_103 seating change evaluation form

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 Online for Free

Quite a few things are quicker than creating files with the help of our PDF editor. There isn't much you have to do to enhance the Dbpr Form Hr 5021 103 document - just follow these steps in the next order:

Step 1: Choose the button "Get Form Here".

Step 2: You can now edit the Dbpr Form Hr 5021 103. The multifunctional toolbar will let you include, delete, adapt, and highlight content or perhaps undertake other sorts of commands.

In order to fill in the form, enter the data the application will require you to for each of the next sections:

Dbpr Form Hr 5021 103 gaps to consider

Enter the appropriate data in the space Menu Restricted see comments, Name Title, Signature, Address, Agency, Date, Phone, SECTION FIRE SAFETY To Be, The above named food service, Employee, Public, Total, Approved, Denied see comments, and Name Title.

Dbpr Form Hr 5021 103 Menu Restricted see comments, Name  Title, Signature, Address, Agency, Date, Phone, SECTION   FIRE SAFETY To Be, The above named food service, Employee, Public, Total, Approved, Denied see comments, and Name  Title blanks to insert

Step 3: After you hit the Done button, the finished document is conveniently exportable to each of your gadgets. Alternatively, you may send it by means of email.

Step 4: It may be better to have duplicates of your file. There is no doubt that we are not going to disclose or read your particulars.

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