Applying for a permit to operate a food establishment in West Virginia involves navigating through the specifics of the SF-5 form, a comprehensive document designed to ensure food safety and public health. Issued by the West Virginia Department of Health & Human Resources, this form captures detailed information about the food establishment, including its name, location, hours of operation, and the type of services provided, such as sit-down dining, takeout, or delivery options. It requires applicants to specify the kind of food establishment they are operating—ranging from mobile or stationary units to various food service entities like restaurants, retail food stores, and institutions like child care centers and hospitals. Additionally, the form delves into ownership details and the identity of the person directly responsible for the establishment’s daily operations. One of the key aspects of the SF-5 form is its focus on the types of meals provided and whether the establishment serves potentially hazardous food, requiring stringent temperature controls to prevent foodborne illnesses. The form also inquires whether the establishment serves highly susceptible populations, stressing the importance of food safety for vulnerable groups. By completing and certifying the accuracy of the provided information, applicants agree to adhere to local food safety regulations and permit inspections, emphasizing the collective effort to maintain high health standards in food service.
| Question | Answer |
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| Form Name | Form Sf 5 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | SF 5_Food_Establis hment_Permit_Ap plication wv sf 5 form |
West Virginia Department of Health & Human Resources |
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Rev 5/08 |
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Department of Health |
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APPLICATION FOR A PERMIT TO OPERATE A FOOD ESTABLISHMENT |
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Food Establishment: Name |
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Phone |
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Mailing Address |
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Location |
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Hours of Operation |
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Applicant: Name |
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Age ≥ 18? |
Mailing Address |
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Yes
No Phone |
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Fax |
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Permit Holder: Permit to be issued to:
Applicant
Corporation
Partnership
Other Legal Entity
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Ownership: |
Individual |
Association |
Corporation |
Partnership |
Other Legal Entity |
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Provide the Name, Title, and |
Address of each person comprising legal ownership (Owners, Officers, Local Resident Agent, etc). |
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Person Directly Responsible for Establishment (Manager,
Name |
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Title |
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Phone |
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Mailing Address |
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Immediate Supervisor of Person Directly Responsible (Zone, District, Regional Supervisor): |
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Name |
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Title |
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Phone |
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Mailing Address |
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Type Establishment: |
Mobile |
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Stationary |
Permanent or |
Temporary ( ≤ 14 days) |
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Restaurant - includes fast food, caterer, commissary, concession stand, bed & breakfast inn, camp, feeding site, etc. |
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Retail Food Store |
- grocery store, convenience store, meat market, etc. |
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Indicate Number of Checkout Stations: |
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Retail Food Store Specialty Department - deli, bakery, seafood, etc. |
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Institution - child care center, hospital, jail, nursing home, personal care home, school, etc. |
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Bar or Tavern |
Vending Machine(s) |
Food Bank / Food Pantry |
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Meals Provided: |
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Breakfast |
Lunch |
Dinner |
Services Provided: |
Sit Down |
Take Out |
Delivery |
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Mail Order |
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Seating Capacity: |
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Average number of meals served per day: |
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Yes |
No |
Serve Highly Susceptible Population (HSP)? |
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HSP includes: preschool children, child care facilities, immunocompromised or older adults, nursing home or assisted living facilities, hospitals, etc.
Type Operation: Attach sample menu or list menu on reverse. PHF means Potentially Hazardous Food, those requiring temperature controls.
No PHF |
Prepackaged |
Limited |
One or two main menu items. Cooking, cooling, reheating limited to 1 or 2 PHF. Limited hot and cold holding of PHF. |
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Limited advanced preparation for next day service. Raw ingredients require minimal assembly. Includes retail food stores, |
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Excluding specialty departments within retail food stores. |
Full |
Preparing PHF using two or more of the following steps: cooking, cooling, reheating, hot or cold holding, freezing, or thawing. |
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Extensive handling of raw ingredients. Advanced prep for next day service. Includes specialty departments in retail food stores. |
I hereby certify that the above information is accurate. Further, I agree to comply with Legislative Rule 64 CSR 17, Food Establishments, and to allow the regulatory authority access to the establishment and to records as specified in that rule.
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Signature of Applicant |
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For Health Department Use Only |
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Date Received |
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Reviewed By |
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Permit Fee |
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Permit
Issued
Denied Date |
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Permit No. |
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Comments |