updated 02/07/02

Name of Business________________________Phone #____________Fax #_____________

Address________________________________________________________________________

                              Street                                                  City                                                      Zip Code

Name and Address of Owner(s):

_______________________________________________________________________________

____________________________________________Home Phone #___________________

_____Restaurant                   _____Tavern                                    ____School/Daycare/Headstart

_____Retail Baker                _____Grocery Store & Deli           _____Mobile Unit

_____Tavern with food       ____Other ________________________________Description

Hours of Operation:_______________________________________________________________

Responsible

Manager________________________________Phone________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please put a check by all that apply:

___Cooling of potentially hazardous foods.

___Preparing and handling (hot or cold) food far in advance (more than 12 hours before serving).

___Extensive handling of raw ingredients and hand contact with ready-to-eat foods. ___Reheating potentially hazardous foods which have been previously cooked and cooled.

___Preparing food for off-site service (where time-temperature requirements during transportation,

holding and service are a factor).

___Vacuum packaging and/or other forms of reduced oxygen packaging are performed at the retail level.

___Serving of immunocompromised individuals (where these individuals comprise the majority of the

consuming population).

___Preparing foods for service from raw ingredients using minimal assembly.

___Hot or cold holding is restricted to same day service.

___Foods requiring complex preparation are obtained from (canned, frozen, fresh prepared) from

approved processing establishments.

___Only pre-packaged foods are available or served.

___Potentially hazardous foods are commercially pre-packaged in an approved processing establishment.

___Have limited preparation of non-potentially hazardous foods and beverages such as snack foods and

carbonated beverages.

___Only beverages are served (alcoholic or non-alcoholic).

Application is hereby made for a Food Service Establishment to operate within Logan County, Illinois. By this application it is agreed that the establishment will comply with the provisions of the Illinois Food Service & Retail Sanitation Codes applicable to this type of food handling establishment. It is further agreed that said food service establishment shall be open to inspection by the Logan County Health Department during normal working hours.

Certified Operator(s):

Name________________________ ID#____________  Expiration Date_____/_____/_____

Name________________________ ID#_____________Expiration Date_____/_____/_____

Name________________________ ID#_____________Expiration Date_____/_____/_____

Name________________________ ID#_____________Expiration Date_____/_____/_____

______________________           _______________________________________________

 Signature of Owner(s)                                   Date

________________________________________________________________________________                      Office Use Only

Permit Issued Date__________________ExpirationDate___________________________

Permit #______________________Class/Category_______________________________

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