Fsi 302 Form – Fill Out and Use This PDF

FSI 302 (1/17)

APPLICATION FOR RETAIL FOOD STORE LICENSE – ARTICLE 28-A

NYS Department of Agriculture and Markets

Attn: Food Safety License Unit

10B Airline Drive, Albany, New York 12235

NOTE: This license is ONLY for retail food stores that do not conduct any type of food processing operations (e.g., prepare sandwiches, cook food on premises). If you conduct food processing operations, you must file a Food Processing Application. Inspections are scheduled after applications are received and reviewed.

(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)You are REQUIRED to be licensed if you offer for sale potentially hazardous food which can include any of the following: milk, shell eggs, refrigerated meats and dairy products. List all of the foods to be covered by this license at the location listed on the front of this application.

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

(7)The undersigned applies for a license to operate a retail food store at this location only, pursuant to Article 28 of the Agriculture and Markets Law of the State of New York and, in support of this application, makes the above statements and agrees to comply with the requirements of Article 28.

The applicant represents that adequate physical facilities, equipment, sanitary controls, records and practices exist to maintain the establishment in a clean and sanitary condition and that the cleaning, maintenance and operation of the establishment is such that products handled therein will not be adulterated.

The issuance of a license is based upon continued compliance with all requirements associated with operating a Retail Food Store.

Applicant consents to free entry and will permit free access to the licensed premises, buildings and offices to the Commissioner, the Commissioner’s agents and inspectors in pursuance of the Commissioner’s duty to supervise and regulate storage, sale and use of articles subject to the Commissioner’s jurisdiction.

NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that this 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.

Applicant understands the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.

In addition to being a basis for denial or revocation of license, any false statements made herein are punishable pursuant to Section 210.45 of the Penal Law of the State of New York.

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: Department of Agriculture and Markets; Attn: Food Safety License Unit, 10B Airline Drive, Albany, NY 12235.