Form Fsi 303 – Fill Out and Use This PDF

FSI-303 (12/2016)

APPLICATION FOR FOOD PROCESSING ESTABLISHMENT LICENSE – ARTICLE 20-C

NYS Department of Agriculture and Markets

Attn: Food Safety License Unit

10B Airline Drive, Albany, New York 12235

This application is only for those establishments that prepare or process food at the location listed below. Inspections are scheduled after applications are received and reviewed. No license will be issued until an establishment receives a satisfactory inspection.

(2)Optional Mailing Address:

(3) Identification Number:

(4)Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members (attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).

(4a.) Principal Office Address:_______________________________________________________________________________________________

(4b.) In what state incorporated?_________________________ (4c.) Date of Incorporation _____________________________________________

(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below which shall constitute good and proper service of process.

(PLEASE COMPLETE REVERSE SIDE)

(5)List all food preparation or processing activities and the food prepared or processed at this location to be covered by this license. For example: cook or heat foods, grind meats, slice cold cuts, cheese, fish, fruit, etc., cappuccino machine, repack ready-to-eat foods or ice.

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(6)Retail Food Stores applying for food processing establishment licenses must submit a copy of its certificate indicating that an individual in a position of management or control assigned to the store has successfully completed an approved Food Safety Course. A list of approved courses can be found on the Department website.

The following retail food stores are exempt from this requirement.

a.Food stores that have as its only full-time employees the owner or the parent, spouse or child of the owner, or in addition not more than two full- time employees.

b.Food stores that had an annual gross income of less than $3 million in the previous calendar year, excluding petroleum products, unless the food store is part of a network of subsidiaries, affiliates or other member stores, under direct or indirect control, which, as a group, had annual gross sales of the previous calendar year of $3 million or more.

Check one of the following:

(7)Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation Insurance (WCI). Indicate your WCI status:

(8)The undersigned applies for a license pursuant to Article 20-C of the Agriculture and Markets Law of the State of New York to conduct the food processing operations listed above, at this location only. New or additional food processing activities are to be reported to this Department for approval prior to the start of the processing operation.

Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application, may be punishable under the provisions of Section 210.45 of the Penal Law of the State of New York.

NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that the applicant, licensee, officer, director, partner or share/stockholder, has been convicted of, or has pled guilty to, a felony in any court of the United States or any State or territory thereof, with respect to an offense involving; food safety, food adulteration or food misbranding.

**PLEASE ENSURE ALL QUESTIONS AND FIELDS ARE ANSWERED/COMPLETED BEFORE PROCEEDING**

Any unanswered questions will result in the denial of your application which PROHIBITS you from operating your business in the State of New York. If your application is denied you must complete and re-submit your application again. Your original application and check will not be returned. Please allow 60 days for application processing and once received post your license in a conspicuous place.

Providing your signature below acknowledges your understanding of requirements listed herein and that you agree to comply with the requirements of Article 20-C.

AUTHORIZATION AND PURPOSE

Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law. The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific license you are seeking. This information is collected to enable the Department to evaluate your application, to determine if it should be issued and to assist in the enforcement and administration of the Agriculture and Markets Law.

If you have questions about the information requested, call (518) 457-7139; e-mail agr.sm.foodlicense@agriculture.ny.gov; or write to: NYS Department of Agriculture and Markets; Attn: Food Safety License Unit; 10B Airline Drive; Albany, NY 12235.