Hr 7030 Form – Fill Out and Use This PDF

DBPR HR-7030 – Division of Hotels and Restaurants Application for Public Food Service Establishment License with Plan Review

NOTE – Please submit completed application with plans, fees and supporting documents in Section 9.

Section 1 – Office Use Only

	Date Received				Initials		$50 One Time Application Fee + License Fees
Month		Day		Year		Check #	Money Order #

Section 2 – License Type

PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE SEATING INFORMATION IF APPLICABLE.

FOR MORE INFORMATION ON FOOD SERVICE LICENSE TYPES VIEW OUR GUIDES: WHICH DO I CHOOSE?

Fixed Establishments:	*	Seating (2010/SEAT)	No Seats (2010/NOST)		Catering (2013/CATR)
Culinary Education Programs:		* With Seating (2023/SEAT)		No Seating (2023/NOST)
*Number of Seats:		(For fee calculation purposes only)

The division does not authorize the number of seats. For seating levels and changes to seating, the applicant must obtain wastewater approvals from the Florida Department of Health, Florida Department of Environmental Protection or the local utility authority. The local authority having jurisdiction must approve fire safety issues relating to seating levels.

Section 3 – Application Information

Please check the appropriate box and provide information as applicable.

		(if previously licensed within the last year by H&R – please provide current license # below)
License Number (change of ownership only)				* Under the Federal Privacy Act, disclosure of
				Social Security Numbers is voluntary unless
Previous Business Name (change of ownership only)				specifically required by Federal statute. In this
				instance, disclosure of social security numbers
Federal Employers Identification Number (FEIN)
				is mandatory pursuant to Title 42 United States
(For businesses and corporations)
				Code, Sections 653 and 654; and sections
Social Security Number (REQUIRED)*				409.2577, 409.2598, and 559.79, Florida
(For president, primary shareholder, partner or individual)				Statutes. Social Security numbers are used to
				allow efficient screening of applicants and
Sales Tax Number (Check if exempt	)
				licensees by a Title IV-D child support agency
				to assure compliance with child support
Opening Date (MM/DD/YYYY)
				obligations.

Section 4 – Owner and Main Address (MA)

Note: This address will be designated as the "address of record" for the owner of this establishment.

FOR ESTABLISHMENTS OWNED OR OPERATED BY PARTNERSHIPS, CORPORATIONS OR COOPERATIVES, please attach a separate sheet or sheets listing the name, address, and social security number of each person who owns 10% or more of the outstanding stocks or equity interest in the licensed activity and the name, address, and social security numbers* of each officer, director, chief executive, or other person who, in accordance with the rules of the issuing agency, is determined to be able directly or indirectly to control the operation of the business of the licensed entity.

Owner Name (please check one: Corporation		Partnership		Individual)
Routing Name (e.g., Management Company, contact name)
Street Address or Post Office Box
City			State		Zip Code (+4 optional)
Florida County (if applicable)			Country
Phone Number	E-Mail Address

Section 5 – Establishment Location Information (LL)

Establishment Name (DBA)

Street Address

2017 June

61C-1.002, FAC

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DBPR HR-7030 – Division of Hotels and Restaurants Application for Public Food Service Establishment License with Plan Review

Section 6 – Mailing Information (LM)

Note: This address will be used by the department for all mailings, including the license.

Complete below or check here if: Same as Section 4 – Owner and Main Address Same as Section 5 – Establishment Location

Routing Name (e.g., Management Company, contact name)

Street Address or Post Office Box

Phone Number		E-Mail Address
	Section 7 - Additional Information
	Is this food service establishment associated with a lodging establishment?		Yes	No
	If yes, indicate the name and license number of the associated lodging establishment below

Is this food service establishment free standing (not within another structure, such as a hotel or mall)?

Yes

No

Section 8 – Supporting Documents

Please attach the following documents:

∙Minimum of two (2) sets of scaled plans, for both new and remodeled, showing all kitchen equipment, plumbing fixtures, bars, storage areas, etc. We will keep one set for our records. You may submit as many sets of plans that you need stamped for local authorities.

∙Proposed Menu (list of specific foods)

∙Proof of Approved Water and Sewer – You may submit a recent copy of water and/or sewer bill as proof of approval. If your business is on a well or septic tank, or if you do not have a copy of your water/sewer bill, please submit a completed EVALUATION OF ONSITE SEWAGE (SEPTIC) AND WATER SUPPLY CAPACITY form with your plans. Your local authority must sign this form. Grease traps must meet all local plumbing codes and be located so they can be easily cleaned.

∙Equipment Specifications (if proposed equipment is not customary for food service operations)

Section 9 – Plan Review Type

Please check the box that best describes your establishment. Please check only one box.

	New		Closed More than 1 Year			Change owner with remodel
	Section 10 – General Information
	Maximum Number			Total Square Footage of			Number of Exits
	of Staff per Shift			the Establishment
	Projected Start Date of Construction					Projected Completion Date of Construction

Approved plans are valid for one (1) year. Extensions must be requested in writing prior to expiration.

Section 11 – Finish Schedule

Please indicate the type of material used in the following areas (for example, quarry tile, FRP, stainless steel, etc.).

Construction finishes must be smooth, easily cleanable and nonabsorbent.

Floor

Wall

Cove Base (Baseboards)

Ceiling

Food Preparation

Food Storage

Dishwashing Area

Bathrooms

Dry Storage

Bar

No studs, joists or rafters may be exposed in areas of moisture. Where the wall meets the floor must be curved and sealed.

2017 June

61C-1.002, FAC

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DBPR HR-7030 – Division of Hotels and Restaurants Application for Public Food Service Establishment License with Plan Review

Section 12 – Dishwashing Facilities – Show On Plans

Manual (3-compartment sink with drainboards or equivalent shelving)

Mechanical (Dishmachine/Glass washer)	Sanitization Method:	Chemical	Heat (Hot Final Rinse)
Section 13 – Other Facilities – Show On Plans

Customers may not go through food preparation, food storage or dishwashing areas to reach the bathroom(s).

	Number of handwash sinks			Number of prep sinks
	Mop sink location			Water heater location
	Section 14 – Fire Safety Equipment – For Reporting Purposes
	Show location of fire extinguishers on plans.
	Types and number of		Minimum 2A10BC			K Class
	each fire extinguisher
	Automatic hood suppression system installed			YES	NO	Required when grease-laden vapors or
						smoke are produced.
	Sprinkler system installed			YES	NO Required if occupancy is over 300.

Section 15 - Signature

SECTION 559.79 (2), FS: Each application for a license or renewal of a license issued by the Department of Business and Professional Regulation shall be signed under oath or affirmation by the applicant, or owner or chief executive of the applicant without the need for witnesses unless otherwise required by law.

I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license.

Complete the application and supporting documents and mail them with the appropriate fees to the address on this form. Please use the entire 9-digit zip code in the address to ensure proper handling.

2017 June

61C-1.002, FAC

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