Form Doh 2249 is a form used to apply for government funding. In order to complete the form, you must provide detailed information about your organization and its purpose. The funding available through this program can be used for a variety of purposes, including expanding your organization's reach or increasing its impact. Completed forms must be submitted by mail or fax. If you have any questions about the form or the application process, please contact the appropriate government agency.
| Question | Answer |
|---|---|
| Form Name | Form Doh 2249 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | doh 2249 doh2249 form |
NEW YORK STATE DEPARTMENT OF HEALTH Division of Environmental Health Protection
Plan Review Fee Determination Schedule
Name and Address of Establishment
Date
m m d d y y y y
Public Water Supply ID
N Y
FOR OFFICE USE ONLY
Cashline #
Amount $
Received by
Improperly completed forms or improperly calculated fees will be returned and may delay processing of your plans.
Instructions to operator for completion of this form: To determine what fee applies to your operation:
A. Exempt - no fee
A. Exemption Request |
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1. |
Is this facility operated by a religious, |
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educational or philanthropic organization? |
Yes |
No |
2. |
Is this facility operated by a municipality |
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(city, town, village)? |
Yes |
No |
3.If the answer to questions 1 or 2 is "yes," you may request exemption from payment of the annual registration fee.
Please indicate documentation that will be made available upon inspection request.
Incorporation Papers Other (specify)
B. All others
B. Locate category type of your establishment on the list below (e.g., food service, temporary residence).
1.Locate the specific capacity which best reflects your operation.
2.Enter the amount indicated under "Fee Calculation" on the right side of the form.
3.Enter total at bottom of form.
4.Sign and date the fee determination schedule.
5.Submit this completed form with fee in the amount indicated under "Total Fee" to the appropriate NYS Department of Health Regional/District Office.
Type of Establishment
Fee
State Sanitary Code
Fee Calculation
Food service establishments, taverns, |
$75 |
Subpart |
bars, caterers, commissaries, etc. |
|
Food Service Establishments |
Hotels, motels,bungalow colonies, cottage colonies, cabins |
Subpart |
|
Number of stories or structures: |
|
Temporary Residences |
1 or 2 |
$50 |
|
3 or more |
$200 |
|
Campgrounds and travel trailer parks |
$100 |
Subpart |
Mobile home parks |
$100 |
Part 17 Mobile Home Parks |
Migrant labor camps |
$50 |
Part 15 Migrant Farmworker Housing |
Swimming pools and bathing beaches |
|
Subpart |
$100 |
Subpart |
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5001 sq. ft. or more, |
$150 |
|
wavepools, slides, spa pools |
$150 |
|
Realty subdivisions (per lot) |
$25 x number of lots |
Sec. 1119, PHL (amended, 1989) |
Community and |
Subpart |
|
Cost of project: |
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Public Water Systems |
Less than $10,000 |
$50 |
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$100 |
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More than $100,000 |
$200 |
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Individual sewage system |
$50 |
Part 75 |
(alternative design) |
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Individual Residential |
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Wastewater Treatment Systems |
TOTAL
Certification Statement: I hereby certify that the statements made above are accurate to the best of my knowledge.
Signature of Operator |
Title |
Date |
.
Note: False statements on this form are punishable as crimes under Article 170 of the Penal Law
Make checks payable to: New York State Department of Health.