On October 1, 2011, the Department of Homeland Security published a new form, FSapp 01 01 11. This form is used to request approval from the DHS to solicit or receive donations from foreign sources. The form must be completed and submitted by anyone who plans to solicit or receive funds from a foreign source for purposes related to the defense of the United States. Organizations that complete this form will be able to continue receiving donations from foreign sources without penalty. Completion of this form is important for protecting both your organization and the United States.
| Question | Answer |
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| Form Name | Form Fsapp 01 01 11 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | fsapplication annual food service license new hampshire form |
STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH SERVICES
FOOD PROTECTION SECTION
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29 HAZEN DRIVE, CONCORD, NH |
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FAX: |
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Website: www.dhhs.nh.gov |
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APPLICATION FOR ANNUAL FOOD SERVICE LICENSE |
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1Full Legal Name of Corporation, LLC or Owner(s) |
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2Name of Establishment |
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3Location (Street) |
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(Town, State) |
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(Zip) |
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4Mailing Address (if different) |
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(Town, State) |
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(Zip) |
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5Telephone # of Establishment ( |
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6Emergency Contact Telephone # ( |
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7Fax # ( |
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8Email Address |
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9Name of Person in Charge at Establishment |
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10Schedule of Operation |
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11Previous Business Name of Establishment |
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12Renting/Space Sharing with another licensee?____No____Yes(enter name) |
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13Type of Ownership |
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14Type of License |
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15Current Establishment # |
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Sole Proprietorship |
Corporation |
New Establishment |
16Current License # |
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Joint Venture |
Limited Liability |
Change in License Class |
17Town Water |
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Yes or |
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No |
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Partnership |
Other (Specify) |
Change of Ownership |
17Town Wastewater Yes |
or No |
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Renewal |
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18Number of Seats (indoor) |
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19Public Water System/(EPA) |
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20Class of License - check highest class and class category |
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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
Class C ($350)
retail food store with one food prep area (1) caterers
FE with
Class D ($225)
FE with
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)
Class G ($100)
bar/lounges with no food prep area that serve alcohol (1) arena/theater concessions serving
senior meal sites (6)
sellers of prepackaged frozen USDA meat or poultry (7)
Class O (No Charge)
municipality operated school cafeterias.
DEFINITIONS
* *Submit all Supporting documentation. Incomplete applications will be returned.
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All |
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New applications only: Floor Plan |
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New/Change of Ownership: |
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I, (print name & title)22,23______________________________________________________, certify that all information provided in or
attached to this application is complete, accurate and
SIGNATURE OF APPLICANT: 24___________________________________________________DATE OF APPLICATION: 25________________
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 |
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Application |
Form FSAPP |
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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
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
11.Previous Business Name of Location - provide the previous name of establishment.
12.Renting/Space
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
SUBMITTING YOUR APPLICATION
1.Payment, payable to “Treasurer, State of New Hampshire,” must accompany application. Payments are non- refundable and
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)
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)
NH Department of Health & Human Services, Food Protection Section |
T:\OCPH\EPI\FPS\Group\2011 Food Rules\Applications\2010 Food Service License |
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Application |
Form FSAPP |
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