Form Fsapp 01 01 11 PDF Details

Navigating the complexities of obtaining an annual food service license in New Hampshire is made straightforward with the FSAPP 01 01 11 form. Provided by the State of New Hampshire Department of Health and Human Services, Division of Public Health Services, Food Protection Section, this comprehensive document serves as an application for businesses seeking to operate within the food industry. It covers a broad spectrum of establishments, from large restaurants to smaller, specialized vendors such as bed and breakfasts and ice cream shops. Key information required includes the full legal name of the corporation or owner, the name and location of the establishment, contact details, type of ownership, the classification of the license being applied for, and specific operational data such as the number of seats and schedule of operation. Additionally, the form requires details about the establishment’s water supply and waste management, underscoring the state's commitment to public health and safety. Applicants are also instructed to include any changes in ownership or license class, with new applications demanding a floor plan and a review fee. It is imperative for prospective and current business owners to provide accurate and complete information to avoid delays in the licensing process. With the FSAPP 01 01 11 form, the path to compliance and successful food service operation in New Hampshire is clearly laid out, ensuring that applicants understand their obligations and the steps needed to meet them.

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Form NameForm Fsapp 01 01 11
Form Length2 pages
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Avg. time to fill out30 sec
Other namesfsapplication annual food service license new hampshire form

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STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES

FOOD PROTECTION SECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29 HAZEN DRIVE, CONCORD, NH 03301-6503

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

603-271-4589

FAX: 603-271-4859 TDD Access: 1-800-735-2964

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Website: www.dhhs.nh.gov

E-mail: foodprotection@dhhs.state.nh.us

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR ANNUAL FOOD SERVICE LICENSE

 

 

 

 

 

 

 

 

 

 

1Full Legal Name of Corporation, LLC or Owner(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2Name of Establishment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3Location (Street)

 

 

 

 

 

 

 

 

 

 

 

 

(Town, State)

 

 

 

 

 

 

(Zip)

 

 

4Mailing Address (if different)

 

 

 

 

 

 

 

 

 

 

 

 

(Town, State)

 

 

 

 

 

 

(Zip)

 

 

5Telephone # of Establishment (

 

)

 

 

 

 

 

 

6Emergency Contact Telephone # (

 

)

 

 

 

 

 

 

 

 

 

7Fax # (

 

)

 

 

 

 

 

 

8Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9Name of Person in Charge at Establishment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10Schedule of Operation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11Previous Business Name of Establishment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12Renting/Space Sharing with another licensee?____No____Yes(enter name)

 

 

 

 

 

 

 

 

 

 

 

 

13Type of Ownership

 

 

 

 

 

 

 

14Type of License

 

 

 

15Current Establishment #

 

 

 

 

 

 

 

Sole Proprietorship

Corporation

New Establishment

16Current License #

 

 

 

 

 

 

 

 

Joint Venture

Limited Liability

Change in License Class

17Town Water

 

Yes or

 

No

 

Partnership

Other (Specify)

Change of Ownership

17Town Wastewater Yes

or No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Renewal

 

 

 

18Number of Seats (indoor)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19Public Water System/(EPA)

 

20Class of License - check highest class and class category

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class A ($875)

food establishment (FE) with 200 seats or more (2) retail food store with 4 or more prep areas (3)

Class B ($450)

retail food store with 2-3 food prep areas (1) FE with 100-199 seats (2)

Class C ($350)

retail food store with one food prep area (1) caterers off-site (2)

FE with 25-99 seats (3) bar/lounges with food prep area (4)

Class D ($225)

FE with 0-24 seats (including but not limited to bakeries) (1) fraternities and sororities (2)

retail food store – self services (4) servicing areas (6)

Class E ($175)

bed and breakfast (1)

ice cream vendors - scooping (2)

lodging facilities serving continental breakfast (3)

Class F ($150)

retail food store - no food prep area (3) wholesalers/distributors TCS food (4)

on-site vending machines - serving TCS food (5) bakeries which do not serve TCS food / 0 seats (6)

Class G ($100)

bar/lounges with no food prep area that serve alcohol (1) arena/theater concessions serving non-TCS food (2) retail food stores serving pre-packaged ice cream only (3) institutions including state, county and municipal institutions (4) private schools (5)

senior meal sites (6)

sellers of prepackaged frozen USDA meat or poultry (7)

Class O (No Charge)

municipality operated school cafeterias.

DEFINITIONS

FE-Food Establishment

TCS-Time/Temperature Control for food safety

* *Submit all Supporting documentation. Incomplete applications will be returned.

21

 

 

All applications-Written results of laboratory analysis of water for bacteria, nitrates and nitrites. (n/a if Town Water)

21

 

 

New applications only: Floor Plan –Include additional $75.00 review fee. See Application Form PRAPP 01-01-11.

 

21

 

 

 

 

 

 

New/Change of Ownership: applications-Septic Approvals for Construction AND Approvals for Operation.(n/a if Town Wastewater)

I, (print name & title)22,23______________________________________________________, certify that all information provided in or

attached to this application is complete, accurate and up-to-date as of the date specified below. I further certify that there are no willful misrepresentations of the answers to questions herein, and that I have made no omissions with respect to any of my answers to the questions presented. I understand that it is my responsibility to immediately notify the Food Protection Section with regard to any changes, corrections or updates to the information provided.

SIGNATURE OF APPLICANT: 24___________________________________________________DATE OF APPLICATION: 25________________

-----------------------------------------------DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY---------------------------------------------------

Date Received___________Check #_______________________Check Amount___________Plan Review Plan Review Check #_______________

Provisional Date_______________S_________R_________Final Date_______________S__________ AUDIT#_________________________________

NH Department of Health & Human Services, Food Protection Section

T:\OCPH\EPI\FPS\Group\2011 Food Rules\Applications\2010 Food Service License

 

Application 12-10.doc

Form FSAPP 01-01-11

 

INSTRUCTIONS FOR COMPLETING

APPLICATION FOR FOOD SERVICE LICENSE

Please fill in all blanks, if not applicable enter “NA”, except steps 14 and 15 (leave blank if not known).

1.Full Legal Name of Corporation or Owner - provide the full legal name of the corporation or owner(s) of the establishment.

2.Name of Establishment - provide the full name of the establishment.

3.Location - provide location of establishment to include street number, street name, city/town, state, and zip code.

4.Mailing Address - provide mailing address if different than establishment location.

5.Telephone # of Establishment - provide the on-site telephone number for the establishment.

6.Emergency Contact Telephone Number - provide telephone number for individual who should be contacted in an emergency.

7.Business Fax Number - for faxing information.

8.Email Address - provide Email address if available.

9.Name of Person in Charge at Establishment - provide the name of the individual who is in charge at the establishment.

10.Schedule of Operation-provide hours,days, and weeks per year this establishment will operate.

11.Previous Business Name of Location - provide the previous name of establishment.

12.Renting/Space Sharing-if yes, indicate name and location of other licensee.

13.Type of Ownership - check the appropriate ownership type of the establishment, if other please specify.

14.Type of License - check the appropriate license type that you are applying for.

15.Current Establishment # - provide current establishment number if known, otherwise please leave blank.

16.Current License # - provide current license number if known, otherwise please leave blank.

17.Town Water/Town Wastewater - circle “Yes” if establishment has town water or wastewater, “No” if it does not. If “No” refer to water and wastewater requirements document.

18.Seating Count – provide total number of indoor seats for the establishment.

19.Public Water System/(EPA) Number – water results sampling number, if applicable.

20.Class of License - check highest class and class category. Example; Class A FE w/200 seats or more.

21.Requirements - check each item applicable and submit supporting documentation.

22.Printed Name - print full name of establishment’s legal owner signing application or officer of legal owner who applies for the license.

23.Title - provide title of establishment’s applicant.

24.Signature - provide original signature of establishment’s applicant.

25.Date - provide current date.

Please note, there are sixteen Self-Inspecting Cities/Towns in the state of NH, in which case you will need to contact directly for licensing if the food establishment is located in those areas. They are: Bedford, Berlin, Claremont, Concord, Derry, Dover, Epsom, Exeter, Keene, Manchester, Merrimack, Nashua, Plaistow, Portsmouth, Rochester and Salem. For contact information, please refer to www.dhhs.state.nh.us.

SUBMITTING YOUR APPLICATION

1.Payment, payable to “Treasurer, State of New Hampshire,” must accompany application. Payments are non- refundable and non-transferable.

2.Incomplete or illegible applications or applications not accompanied by payment, water test results, product list, or any other applicable attachments, will be returned. Completed application(s) should be forwarded to the Food Protection Section, 29 Hazen Drive, Concord, NH 03301.

3.For “Change in License Class, New or Change of Ownership” applications. Thirty (30) days after forwarding this application with all the required applicable paperwork to the Food Protection Section, call (603) 271-4589 to leave a message for your inspector to arrange for an inspection of your facility. (Please allow seven (7) business days notice for inspection appointment)

For additional information or for further assistance, please contact the NH Department of Health and Human Services, Division of Public Health Services, Food Protection Section at (603) 271-4589 or foodprotection@dhhs.state.nh.us.

NH Department of Health & Human Services, Food Protection Section

T:\OCPH\EPI\FPS\Group\2011 Food Rules\Applications\2010 Food Service License

 

Application 12-10.doc

Form FSAPP 01-01-11

 

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