Form Sf 5 is an important form that all self-employed individuals must file to report their income and social security taxes. This form is due every year on April 15th, and it's important to make sure you understand the requirements so you can accurately complete and submit your form. The instructions for Form Sf 5 are very detailed, but this article will provide a brief overview of the most important points so you can be sure to have everything you need. Keep in mind that since this is a complex form, it's always best to consult with a tax professional if you have any questions.
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 |
or |
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 |