DBPR HR-7007: Application for Public Food Service Establishment License

Check the appropriate box and provide additional information as applicable.

Under Fixed Establishments, ** Seating (2010/SEAT): enter the Number of Seats (required to calculate fees).

The division does not authorize the number of seats. For seating levels and changes to seating, the applicant must obtain wastewater approvals from the Florida Department of Health, Florida Department of Environmental Protection or the local utility authority. The local authority having jurisdiction must approve fire safety issues relating to seating levels.

For Culinary Educations Programs please submit documentation verifying the establishment meets statutory education requirements.

Enter the Vending Machine Serial Number.

Enter the Vehicle Identification Number (VIN) for MFDVs.

MFDVs - Is this vehicle self-sufficient? Yes No If “No”, you are required to provide commissary information for approval.

Check New Establishment or Vehicle or Change of Ownership (previously licensed within the 18 months by H&R). For Change of Ownership, enter the License Number and Previous Business Name.

Plan Review Requirement: check Completed - File Number or In progress - File Number and enter the file number. All food service locations that have not held a license with this division within one calendar year and existing food service locations that have been remodeled require plan review. For faster processing, please include a copy of your letter from the Plan Review Office with your application or provide your file number in Completed - File Number or In progress - File Number. Enter the Federal Employers Identification Number (FEIN) (For businesses and corporations).

Check Not required, or check Not required - Caterer using existing H&R licensed kitchen and enter the License Number.

Enter the Social Security Number (REQUIRED) for the president, primary shareholder, partner or individual.

Under the Federal Privacy Act, disclosure of social security numbers is voluntary unless specifically required by Federal statute. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes.

Enter the Sales Tax Number or check if exempt.

Enter the Opening Date (MM/DD/YYYY).

Section 3 - Owner and Main Address (MA) will be designated as the “address of record” for the establishment. Enter the Owner Name and check one: Corporation, Partnership or Individual.

For establishments owned or operated by partnerships, corporations or cooperatives, please attach a separate sheet or sheets listing the name, address, and social security number of each person who owns 10% or more of the outstanding stocks or equity interest in the licensed activity and the name, address, and social security numbers of each officer, director, chief executive, or other person who, in accordance with the rules of the issuing agency, is determined to be able directly or indirectly to control the operation of the business of the licensed entity.

Enter the Routing Name (e.g., Management Company, contact name).

Enter the Street Address or Post Office Box, City, State, Zip Code (+4 optional), Florida County (if applicable), Country, Phone Number and E-Mail Address.

Section 4 - Establishment Location Information (LL) is the physical location address. For mobile food dispensing vehicles and hot dog carts, enter the commissary address. For self-sufficient vehicles that do not use a commissary, enter the water/sewer location address. Enter the Establishment Name (DBA).

Enter the Street Address, City, Zip Code (+4 optional), Florida County, Phone Number and E-Mail Address.

Section 5 - Mailing Information (LM) will be used for any mailings. Check Same as Section 3 - Owner and Main Address or Same as Section 4 - Establishment Location, or complete the boxes: Routing Name (e.g., Management Company, contact name).

Fill in the Street Address or Post Office Box, City, State, Zip Code (+4 optional), Florida County (if applicable), Country, Phone Number and E-Mail Address.

Is this food service establishment associated with a lodging establishment? Check Yes or No. If yes, indicate the name and license number of the associated lodging establishment in Name of Lodging Establishment and License Number of Lodging Establishment.

Is this food service establishment free standing (not within another structure, such as a hotel or mall)? Check Yes or No.

“I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true.”

I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license.

Enter the Applicant Name and Applicant Title, sign on the Signature line and enter the Date.