In the journey to establish or maintain a food establishment within the Commonwealth of Virginia, the CSHD 4.29 form emerges as a critical document. This comprehensive form, administered by the Department of Health's Central Shenandoah Health District, serves multiple purposes including applications for new establishments, renewals, name changes, and ownership transitions. It meticulously gathers details about the establishment such as its name, contact information, physical and mailing addresses, and the nature of the food establishment—be it stationary or mobile, temporary or permanent. Additionally, it delves into the specifics of food handling practices to ensure compliance with health regulations, asking pointed questions about the preparation, storage, and serving of potentially hazardous foods. The form also requires information on the legal owner, the registered agent if applicable, and the person directly responsible for the establishment's daily operations, making it a pivotal tool for regulatory oversight. Alongside catering to the logistical aspects, it also touches on public health considerations, such as whether the establishment intends to allow smoking and provisions for water supply and sewage disposal, ensuring that every facet of food service and public health is addressed. Completeness and truthfulness in submitting this form not only facilitate the smooth processing of the application but also affirm an establishment's commitment to upholding food safety and public health standards as outlined by the Commonwealth of Virginia Board of Health Food Regulations.
| Question | Answer |
|---|---|
| Form Name | Form Cshd 4 29 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Food Est Permit commonwealth of virginia department of health food establishment permit application form |
COMMONWEALTH OF VIRGINIA
Department of Health
Central Shenandoah Health District
Food Establishment Permit Application
Application for a: |
New establishment |
Renewal |
Name change |
Change of owner |
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Name of establishment: ____________________________________ |
Telephone: ___________________ |
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Mailing address: __________________________________________ |
Fax: _________________________ |
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___________________________________________ |
Physical location common name and address: |
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___________________________________________ |
__________________________________________ |
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___________________________________________ |
__________________________________________ |
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Applicant’s name: ___________________________ |
Title: ____________________________________ |
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Mailing address: ___________________________________________________________________________
Telephone:_________________________________ |
Email address: ____________________________ |
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Legal owner type: |
Association, |
Corporation, |
Individual, |
Partnership, |
Other legal entity |
Legal owner name: ________________________________________ |
Telephone: ___________________ |
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Legal owner mailing address: ________________________________________________________________
__________________________________________________________________________________________
Billing address: ____________________________________________________________________________
If legal owner is other than an individual, please attach a list of names, titles, and addresses of all persons comprising the legal ownership.
Local registered agent (if required – out of state corporations must identify registered agent for Virginia)
Name: __________________________________ |
Title: ___________________________________ |
Address: ________________________________ |
Telephone: ______________________________ |
________________________________________ |
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Person directly responsible for the establishment |
Immediate supervisor of responsible person |
Name: _________________________________ |
Name: _________________________________ |
Title: __________________________________ |
Title: __________________________________ |
Address: _______________________________ |
Address: _______________________________ |
_______________________________________ |
_______________________________________ |
Telephone: _____________________________ |
Telephone: _____________________________ |
CSHD # 4.29 (2 pgs.) |
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Pub. 12/09 |
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Is the food establishment: (check appropriate box) |
stationary or |
mobile |
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Is the food establishment: (check appropriate box) |
temporary or |
permanent |
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Does the establishment: (check Yes or No) |
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(1) Prepare, offer for sale, or serve potentially hazardous food: |
Yes or |
No |
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(a)Only to order upon a consumer’s request Yes or No
(b)In advance quantities Yes or No
(c)Using time as the public health control Yes or No
(2)Prepare potentially hazardous food in advance using a food preparation method that involves two or more steps which may include combining potentially hazardous food ingredients, cooking, cooling,
reheating, hot or cold holding, freezing, or thawing |
Yes or |
No |
(3)Prepare food as specified under (2) for delivery to and consumption at a location off premises of the food establishment where it is prepared Yes or No
(4)Prepare food as specified under (2) of this section for service to a highly susceptible Population (i.e., the elderly, children, or those with weakened immune systems) Yes or No
(5)Prepares only food that is not potentially hazardous Yes or No.
The terms above in ITALICS are defined in the Commonwealth of Virginia Board of Health Food
Regulations.
The Commonwealth of Virginia Board of Health Food Regulations can be found at: http://www.vdh.virginia.gov/EnvironmentalHealth/Food/Regulations/index.htm
Please Attach a Proposed Menu |
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Do you intend to allow smoking? |
Yes |
No, If yes please indicate Inside or Outside, the Establishment |
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Total number of seats: ___________ |
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Water Supply: (check appropriate box) |
Public - Name ___________ or |
Private - Type _____________ |
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Sewage: (check appropriate box) |
Public - Name _____________ or |
Private - Type ________________ |
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I/We attest to the accuracy of the information provided, affirm to comply with the Food Regulations, allow the regulatory authority access to the establishment at any reasonable time to inspect, conduct tests or collect samples as required, and agree to accept notices issued and served by the regulatory authority.
**It is the responsibility of the person in charge to have a general knowledge of the Food Regulations as they pertain to their establishment.
Signature: ___________________________________ |
Title: _____________________________ |
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Print Name: _________________________________ |
Date: _____________________________ |
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Office use ONLY |
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Property Identifier: ____________________ |
Tax Map #: _______________ |
Subdivision: ____________________ Section: |
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_____________________________ |
Block: ___________________ Lot: ___________________________ |
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GPIN#: _____________________________ Census Tract: __________________________ |
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Facility Type: ________________________Chain or Franchise: _____________________ |
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Approved for Permit: (Y or N) __________ |
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By: __________________________________ |
Date: ______________ |
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Date Signed: ________________ |
By: __________________________________ |
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Date Issued:_________________ |
By: __________________________________ |
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CSHD # 4.29 (2 pgs.)
Pub. 12/09