Embarking on the journey of launching or maintaining a retail food business in New York brings its own set of challenges and formalities, one of which involves navigating through the application process for a Retail Food Store License. Specifically, the FSI 302 form is a gateway for businesses to legally operate under the state’s scrutiny, aiming to ensure food safety and public health. Established by the New York State Department of Agriculture and Markets, this application is designed with a dual purpose: to regulate retail food stores and uphold the highest standards of food safety. A $250 license fee is a small part of the bigger picture, where applicants are meticulously vetted, including checks on the physical facilities, sanitary conditions, and even the moral standing of the business operators with respect to food safety laws. This form, effective from January 2017, outlines a comprehensive procedure requiring an original signature from the owner or a corporate officer, verification of food safety compliance, and a declaration of the adherence to workers' compensation law, among other mandates. It underscores the state’s commitment to food safety by regulating retail establishments selling potentially hazardous foods without engaging in food processing operations. Moreover, the form serves a broader purpose by collecting essential data that aids in the administration of food safety laws, aligning business operations with state regulations, and ensuring that the essentials like milk, eggs, and refrigerated meats comply with safety standards. A thorough understanding of the FSI 302 form is crucial for anyone looking to venture into the retail food industry within New York, ensuring they meet all necessary legal and safety requirements, demonstrating the state’s meticulous approach in safeguarding public health through diligent regulatory measures.
| Question | Answer |
|---|---|
| Form Name | Fsi 302 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | application retail food form, application retail food, 302, WCI |
FSI 302 (1/17)
APPLICATION FOR RETAIL FOOD STORE LICENSE – ARTICLE
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
LICENSE FEE $250.00
License Expiration: Two years from date of issuance.
Office Use Only
County Code- Est. No.
Entity No. _________________________
Receipt No. ________________________
Verification No. ____________________
INSTRUCTIONS
Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is required in Section (7).
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.
(1) Individual Owner Name, Partnership or Full Name of the Corporation: |
County: |
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Trade Name: |
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Business Telephone Number: |
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Street: |
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State: |
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Bank Name: |
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(2)Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number |
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Social Security Number |
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(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
Name (Please Print)
Title
Contact Address (Street & No., City, State, Zip)
Date of Birth
(4a.) Principal Office Address: ______________________________________________________________________________________________
(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation_____________________________________________
(4d.) Are you a foreign or |
Yes |
No |
(4e.) For foreign or |
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Date of filing in New York State? ____________________ |
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(4f.) If
Designated:______________________________________ |
Address: _______________________________________________________ |
(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:
Insured with __________________________________________________
Name of Insurance Provider
Self Insured
Exempt from WCI
(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.
ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER
TITLE
DATE
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)
On e Tim e Cr e d it Ca r d Pa y m e n t Au t h or iz a t ion For m
Sign and com plet e t his for m t o aut hor ize t he NYS Depar t m ent of Agr icult ur e and Mar k et s t o m ak e a on e t im e debit t o y our cr edit car d list ed below . Please m ail t o t he below addr ess.
By signing t his for m y ou giv e us per m ission t o debit y our account for t he am ount indicat ed on or aft er t he indicat ed dat e. This is per m ission for a single t r ansact ion only , and does n ot pr ov ide aut hor izat ion for any addit ional unr elat ed debit s or cr edit s t o y ou r account .
Ple a se com p le t e t h e in f or m a t ion b e low :
I_________________________________ , aut hor ize t he NYS Depar t m ent of Agr icult ur e and Mar k et s t o char ge m y cr edit car d account indicat ed below for $ 2 5 0 . 0 0 . This pay m ent is for a:
RETAI L FOOD STORE LI CEN SE
Billing Addr ess ________________________________ |
Phone# ________________________ |
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Cit y _________________________________________ |
St at e _______ |
Zip ________ |
Em ail ____________________________________________________________________________ |
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Account Ty pe: |
Visa |
Mast er Car d |
AMEX |
Discov er |
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Car dholder Nam e _____________________________________________ |
FOR OFFI CE U SE ON LY |
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Account Num ber |
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Est ab No. : __________________ |
Ex pir at ion Dat e |
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License No. : _________________ |
CVV2 ( 3 digit num ber on back of Visa/ MC, 4 digit s on fr ont of AMEX) _______ |
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SI GNATURE |
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I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for a Retail Food Store License, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card.
Division of Food Safety & Inspection │ 10B Airline Dr. Albany, N.Y., 12235 │ (518)