HEALTH. 2. You must submit a written agreement with an approved commissary, as detailed in the accompanying fact sheet, with your application packet.

Transcription

1 ~~~;~~fk ==============If 1============ Nirav R. Shah, M.D., M.P.H. Commissioner HEALTH Sue Kelly Executive Deputy Commissioner Dear Mobile Food Operator: Please review the below information prior to submitting an application for a Permit to Operate a Mobile Food Service Establishment, as defined in Subpart 14-4 of the New York State Sanitary Code- (SSC). 1. Please fill-out all portions of the application and associated paperwork COMPLETELY. The information provided will be used to determine your eligibility for a Permit to Operate, and submission of an incomplete application may delay the approval process. Every mobile unit and pushcart must have an associated commissary, unless ONLY pre-packaged food is served. 2. You must submit a written agreement with an approved commissary, as detailed in the accompanying fact sheet, with your application packet. 3. All permits-for mobile food units and pushcarts are issued ANNUALLY. You will have to re-submit the applicable information and associated fees every year. Please ensure the enclosed application and fee determination schedule is completed fully. 4. If your base of operations is outside the District served by this office (Warren, Saratoga or Washington Counties), we will need a copy of the permit for your associated commissary. Your private residence cannot be used as a commissary. 5. If you strictly operate in this District at fairs, carnivals, or other temporary events, you will be issued a Temporary Food Service Establishment Permit (in accordance with NYSSC Subpart 14-2), for each event. This office will not issue Mobile Food Service. Establishment Penn its to any unit without a valid approved commissary. New York State Sanitary Codes, Subparts and require that a valid Permit to Operate be obtained from the permit-issuing official having jurisdiction prior to the operation of a Mobile or Temporary Food Service. Please contact this office at (518) with any questions. Sincerely, ;e~'j,!-l- Richard Hess Public Health Sanitarian P:\DAT A\GFDO OFFICE FORM LETTERS\Mobile Food Cover Letter.doc HEALTH.NY.GOV lacebook.com/nysdoh twitter.com/healthnygoy

2 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Application for a Permit to Operate Complete all items that apply to your establishment. All applicants must complete sections A, 8, G, & H. If you have any questions, contact the local health department issues your permit. that Facility Name, Facility Address, Telephone Number, Fax Number and Municipality: Self explanatory Capacity A. Food services: enter actual seating capacity, or enter 00 for take out only. B~ Recreational vehicle parks, campsites, agricultural fairgrounds and mobile home parks: enter the number of actual sites. C. Children's camp: enter the maximum number of campers the camp Is approved for at one time. D. Temporary residences and migrant farmworker labor camps, swimming pools, bathing beaches, mass gatherings: enter the maximum number of people the facility is approved to hold.. E. Recreational aquatic spray ground: enter 00, F, Tanning Facility: enter the tcital number of tanning devices. Facility Status: Check either profit or nonprofit. If nonprofit, submission of documentation (incorporation paper) verifying status may be required. Facility Type: From ttre fist below enter the facility type that best describes the main or primary operation of the facility. Some multiple operation facilities may require submission of separate permit application(s). Please consult the health department that issues your permit with any questions. Facility Agricultural Bathing Freshwater Types: Beache. Fairground. River Impoundment/Pond lake Ocean Surf Other Saltwater Campground/Recreational Vehicle Park Children'. Day Camp Camp. Day Camp - Developmentally Day Camp - Municipal Day Camp - Traveling. Ovemight Camp Disabled. Oveniight Camp - Developmentally Disabled Overnight Food Service Restaurant Caterer School Institution Camp - Municipal Establishment State Office for the Aging (SOFA) - Prep Site State Office for the Aging (SOFA) - Satellite Site Summer Feeding Program (USDA) - Prep Site Summer Feeding Program (USDA) - Satellite Site Mas. Gathering Migrant Farm Worker Housing Farm labor Mobile Mobile Housing Home Park. Food Recreational Aquatic Spray Ground. Indoor Outdoor Swimming Indoor Outdoor Pool. Indoor/Outdoor Wave Pool- Wave Pool- Wave Pool- Indoor Outdoor Indoor/Outdoor Aquatic Amusement - Indoor Aquatic Amusement - Outdoor Aquatic Amusement ~ Indoor/Outdoor Spa Tanning Temporary Facility Food Temporary labor Residence. Camps other than Migrant Interior Corridor - Single Story Interior Corridor - Two Story Interior Corridor - Three Story Interior Corridor - Four or more Story Exterior Corridor - Single Story Exterior Corridor - Two Story Exterior Corridor - Three Story Exterior Corridor - Four or more Story Cabin or Bungalow Colony Vending Food Machine. State Agency Licensed Facilltle. State licensed Inspected Facility State Owned Operated Facility Day Care Center - Residential Day Care Center - Non-Residential DOH-3915 (1I11) p. 1 of 4

3 t: ' -'NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Complete all items that apply to your establishment(all applicantsmust complete SectionsA, B, G and H), sign on the back page and retum with the appropriate fee at least 30 days prior to the expectedopeningdate to: New York State Dept. of Health Glens Falls District OffICe 77 Mohican Street Glens Falls, N'Y (518) ':;$~~"t.lqt!~f~~i!~,~~:r.~~~!1~,(~~f!:~~t@l\m4~(~'~pr't!~b~"!f~~pi~~~~j.ii~&~1:~i,:f!j Facility name Facility address City S,tate Zip Telephone no. Ll, Fax no. Ll Municipality [1] M [C] Capacity L-[ J Facility Status [ I Profit [ I Non-profit Facility Type... [ ~l Indicate days operation is open S M T W T F S I,'I, I I, I, I AM I " I, I AM Expected opening datell.l.-l...j Expected closing datel I I I I Hours of operation LL.l.-L...J PM L.LL...L...J PM Month/Day ~ Open Close Water Supply U Public (municipal) U Private (onsite) Sewage System U Public (municipal) U Private (onsite) Number of operations under this registration LJ Indoor Pools L.J Bathing Beaches LJ Food Services l--.j Day Camps LJ Outdoor Pools L.J Spa Pools LJ Recreational Aquatic Spray Grounds LJ Tanning Devices SECTION B: Operator/Owner Infonnatlon (E'ntlre sect/on must be completed by au applicants.) Legalopera~r~ope~tingco~o~tion~--~~~ (If corporatlon or partnership. Section F must be completed.) Person in charge Telephone no. (), Fax no. () Permanent address address City State -----'- Zip Employee Identification Number U L.J UUUL.JL.JL.JL.J Owner.:.- Telephone Ll Or Social Security Nuniber UUU-L.JU-L.JL.JL.JL.J Permanent address City State Zip SECTlO~ C: Complete for temporaryfooct Servlu'estabU.hrrient$ only {attach add/tiona' sheet. as nee sary'i,' Name and location of event Name of Foods Supplier of ingredients Where and how foods will be prepared and served I DOH-3915 (1/11) p I

4 Caterers, Commissaries, Temporary Food Mobile Vendors & Frozen Desserts (free-standing) Fee Determination Schedule NEW YORK STATE DEPARTMENT OF HEALTH As required by Article 6, PHL, effective 1/1/88 Fee Exemption Requested? Yes If Yes, complete sections No A, C and D below and return. INSTRUCTIONS >~i~;~~i~!i!!!~ ::::::::::: Print or type the requested information. Determine the correct fee. Make your check payable II to the New York State Department of Health. Mail the completed form and your check to the appropriate Department of Health Regional or District Office within 30 days of receipt of this form. 1a. Name of Establishment b. Federal ID Number 2. Type of Operation: Caterer or Commissary Mobile Vendor Temporary Food Frozen Dessert 3. Name of Operator Title 1. Check the appropriate category to determine the total fee due. Caterer or Commissary $ Temporary Food or Mobile Vendor $30.00 Frozen Dessert (free standing) $25.00 TOTAL FEE DUE: $ 1. Is this facility used for religious, educational or philanthropic purposes? 2. Is this facility operated by a municipality (city, town, village)? 3. If the answer to questions 1 or 2 is "yes" you may request exemption from payment of the annual registration fee. Please indicate documentation that will be made available upon inspection request. Incorporation Papers Other (specify) ~~qt!gnp~g~rtifi~!h9hf%r ~$t~i~m~qt 9gmj ~pp@~tj r)~r~pyqj h~ t yr)~~r~rt@l~j7p9f1h~r r)~lg~vi; I hereby certify that the statements made on this form are accurate to the best of my knowledge. Date DOH-22250) 10/92

5 MOBILE FOOD SERVICE FACT SHEET 1. All mobile food units and pushcarts must operate out of an approved commissary. The commissary is a location where the food is stored, processed or packaged. Each unit and its equipment are cleaned and maintained at the commissary. The commissary must be inspected and operated under a Permit issued by the New York State Department of Health or other regulatory agency acceptable to the Department. 2. The commissary must meet all of the requirements of Subpart 14-1 (Food Service Establishments) of the New York State Sanitary Code or another appropriate regulatory authority (such as the Department of Agriculture & Markets, FDA, USDA etc.), and must also meet all requirements of Part 5-1 (Public Water Supplies). 3. A plan must be submitted for review and approval of all home made pushcarts or mobile units. Specifications must be submitted for approval of all commercial units. 4. Mobile units must have a sink with hot water provided. A minimum capacity of 40 gallons of potable water storage and 50 gallons of wastewater storage are required. 5. All water provided must meet the requirements of Part 5-1 of the New York State Sanitary Code (such as commercially bottled water, etc.). All ice must be from a commercial approved source. Food and beverage containers cannot be stored directly in ice used for consumption. 6. Each mobile unit or pushcart must obtain an Annual Permit to Operate. In addition, ail annual permit fee is required. Applications must be submitted at least 21 days prior to the first day of operation. 7. Mobile food unit operators who currently posses a mobile food Permit to Operate issued from a local County Health Department must apply for and receive a Permit to Operate from the Glens Falls District Office in order to operate in Saratoga, Warren and Washington Counties. This requirement does not apply to operators who have a current, valid Permit to Operate from another New York State District Office. P:\DATA\Mobile Food Fact Sheet.doc

6 NVS Workers' Compensation and Disability Insurance Fact Sheet Please read ~his information carefully. Incomplete applications will not be processed by this office ' NYS Workers' Compensation Law requires the Glens Falls District Office to ensure that any entity applying for a Permit to Operate have appropriate Workers' Compensation and Disability Insurance coverages. As such, proof of insurance coverage or proof of exemption from coverage must be provided at the time of submission of an Application for a Permit to Operate (DOH-3915) or renewal application for a Permit to Operate (DOH-3965). Applications submitted to the Glens Falls District Office without the above-mentioned proof of coverage or proof of exemption will not be processed. It Is illegal to operate without a v,lid permit. Doing so could result In fines of up to $2, per day. Proof of Workers' Compensation Insurance coverage requires the submission of a valid Certificate of Workers' Compensation Insurance using the following signed forms: Form C10S.2, Form U-26.3, Form SI-12, or GSI-10S.2. Proof of Disability Insurance coverage requires the submission of a valid Certificate of Disability Benefits using the following signed forms: or Form 08-15S. If you qualify for an exemption from Workers' Compensation and Disability Insurance, you must submit a signed Form CE Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage to this office with your Application for a Permit to Operate, or renewal application for a Permit to Operate. Information regarding Workers' Compensation and Disability Insurance can be obtained from the NYS Workers' Compensation Board website at If applicable, Form CE Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage must be completed on-line, and can be found by following the hyperlinks: "Employer/Businesses", "WC/DB Exemptions" (at bottom of web page), "Request for WC/DB Exemption (Form CE-200)". A completed and signed (original signature only) Form CE Certificate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage must be submitted with every application, and may not be used for more than one application submission (for example, a Form CE-200 submitted with an application for a building permit may not be submitted with another application to the Glens Falls District Office, or to any other government entity). All questions regarding Workers' Compensation and Disability Insurance, including obtaining all forms, must be brought to the NYS Workers' Compensation Board by visiting their web site ( or contacting one of the Customer Service Centers located in Workers' Compensation Board District Offices. The closest office is located at 100 Broadway, Menands, NY 12241, and can be contacted at (866) or by fax at (518) The Glens Falls District Office cannot provide internet access, provide any of the aforementioned forms, or answer any questions regarding coverage for Workers' Compensation or Disability Insurance. You must contact Workers' Compensation Board directly.. P:\DATA\GFDO OFFICE FORMS\Workers' Compensation and Disability Insurance Fact Sheet 2.doc

7 Mobile Food Service Questionnaire Operators Name Address Mobile Unit Name Total Number of Units Type of Unit Motorized Pushcart Motor Vehicle Lie. Number for each unit Commissary Name & Address Does State, County or Local Authority permit your commissary. Y N (Please submit an agreement with your commissary similar to the enclosed example.) Water Supply for your commissary. Public Private If Private source Well Surface Treated Y N Menu for your operation Source of your food supplies -'- H/Data/MobileFoodQuestionnaire.doc

8 AGREEMENT I AGREE TO ALLOW THE USE OF MY FACILITY AS A COMMISSARY FOR THE MOBILE UNIT (S) OWNED AND OPERATED BY THIS USE INCLUDES FOOD STORAGE AND PREPARATION. WASHING AND SANITIZING OF UTENSILS. MAINTENANCE OF THE UNIT ITSELF AND ACCESS TO MY WATER SUPPLY TO FILL THE MOBILE UNIT. Date of Agreement Expiration of Agreement Signed Commissary Owner/Operator Permit No. As assigned by NYS Dept of Health or NYS Dept. of Agriculture and Markets H/OataiMobilFoodCommissaryAgreement.doc