GUIDE TO OBTAINING A PERMIT TO OPERATE A FOOD SERVICE … · 2020-01-22 · GUIDE TO OBTAINING A...

GUIDE TO OBTAINING A PERMIT TO OPERATE A FOOD SERVICE

ESTABLISHMENT

Plans are reviewed by appointment ONLY. Call (518) 565-4870 for an appointment.

All plans* must be submitted at least 30 days BEFORE the planned construction date.

*Completing this application does not constitute approval to operate. You must receive a Permit to Operate with the Permit Issuing Official’s signature. After the plans are approved, construction may commence. Construction must be done in accordance with the approved plans. Consult the Health Department before making any changes to your approved plans. When construction is complete and all equipment is installed, call 518-565-4870 to schedule a pre-operational inspection. Please allow several days to schedule the inspection. This inspection must be completed before a permit to operate can be issued.

K/FORM LETTERS & FORMS/Form Letters-FSE/FSE Guide & Plan Review/FSE Permit Guide 01/2020

Clinton County Health DepartmentEnvironmental Health and Safety Division

135 Margaret StreetPlattsburgh, NY 12901Phone 518-565-4870

Fax 518-565-4843

TABLE OF CONTENTS Page(s)

Instructions/Checklist 3 Fee Schedule 4 Application for Approval of Plans 5 Details of Food Service Operation 6-9Floor Plan Example 10 Example Schedule of Equipment 11 Food Service Establishments Not on Public Sewage 12 Instructions for Facility Basic Data Sheet 13 Facility Basic Data Sheet 14-15Temporary Food Service Supplement 16-18Mobile FSE Details 19 Mobile FSE Layout 20 Mobile FSE Plumbing and Disinfection Procedures 21 Off-site Catering Plan Requirements 22 Use of Commissary/Shared Kitchen Agreement 23 Application for a Permit to Operate – Instructions 25-26Application for Permit to Operate 27-28Corporation Forms 29-32Workers’ Compensation and Disability Insurance Forms Instructions 33-34

INSTRUCTIONS/CHECKLIST–FOOD SERVICE GUIDE This Guide is detailed and comprehensive. It is recommended that you work closely with a

Health Department representative to complete the required documentation.

��

The following items must be submitted before your plans will be reviewed

Resta

ura

nt

Mobile

Food

Serv

ice

Tem

pora

ry

Food

Serv

ice

Cate

ring

Serv

ice

Completed Application for Approval of Plans (page 5) • • • •

Completed Details (pages 6-9) of the food service operation • • • •

Two (2) adequately sized copies of the floor plans showing the necessary specifics. (See example on page 10). The plans must be accurate, legible and drawn to scale. Hard copies only are accepted, electronic copies are not acceptable

• •

Equipment schedule. See example on page 11 • • • •

WATER SUPPLY (check one) Public ___ or Private___. • • • •

WATER SUPPLY If not connected to a Municipal/Public Water System, you must complete and attach a completed “Water System Disinfection Application Packet” This application is a separate document available at www.clintonhealth.org or by calling 518-565-4870.

• • • •

SEWAGE TREATMENT SYSTEM (check one) Public ___ or Private___. • • • •

SEWAGE TREATMENT SYSTEM If not connected to a Municipal/Public Sewer System, you must complete page 12 and attach existing or proposed Sewage Treatment System Plans. The sewage treatment system application for a new system producing less than 1,000 gallons/ day is a separate document available at www.clintonhealth.org or by calling 518-565-4870.

• • • •

PRIVATE SEWAGE TREATMENT SYSTEM over 1,000 gallons/day must obtain a SPDES permit from NY State Department of Environmental Conservation

• •

Completed Facility Basic Data Form (page 14 & 15) • • •

A copy of menu • • • •

Completed “Application for a Permit to Operate” pages 27 to 28 NOTE Permit application must be signed by owner.

• • • •

Proof of Workers Compensation and Disability Insurance Coverage if required or waiver if not required. See pages 33 to 34.

• • • •

Corporation Officer and Partner Form completed and signed if required. Pages 30 to 31.

• • • •

Permit Fee – See page 4 for correct fee. NOTE this is an annual fee and is not pro-rated. Cash or Check made out to Clinton County Treasurer

• • • •

Temporary Food Service (14 days or less/year) must compete and submit pages 16 to 18

•

Mobile Food Service must compete and submit pages 19 to 21 •

Catering Operations must compete and submit page 22 and the required attachments 1-4 described on page 22

•

Use of Commissary/Shared Kitchen Agreement – page 23 • • •

PERMIT FEES Effective January 1, 2020

High Risk $200.00 Medium Risk $125.00

Low Risk $85.00 Additional fee per Vending $40.00

Mobile Cart or Truck $105.00 Temporary $85.00

Not-For-Profit Groups $30.00 If on-site water (not on Municipal supply) include additional Fee: $55.00 If on-site sewer (not on Municipal supply) include additional Fee: $55.00

*The Sanitarian who reviews your plans will determine the Risk status of your facility

APPLICATION

FOR APPROVAL OF PLANS AND SPECIFICATIONS FOR THE CONSTRUCTION, ALTERATION OR REMODELING OF A

FOOD SERVICE ESTABLISHMENT

CLINTON COUNTY HEALTH DEPARTMENT (CCHD) Environmental Health Services Division

133 Margaret Street Plattsburgh, NY 12901

(518) 565-4870

NOTE: This application must be accompanied by complete submissions (Including water supply and sewage treatment if applicable).

Name of Establishment: Name of Intended Permit Holder: Mailing Address: 911 Address, including Town, Village, City, County: Contact Person: Telephone Number: Email Address: Name of Architect, Engineer or Food Service Consultant: New Facility____ Remodel____

(check one) Was this facility previously a restaurant? yes___ no___ Name__________________ Last year it operated_________

This application must be signed by the permit applicant or the proper official(s) of the corporation or legally constituted board of commission having charge of work. The signature of the designing engineer or other agent will be accepted if accompanied by a letter of authorization.

X

Signature of Applicant Official Title Mailing Address

FOR OFFICE USE ONLY:

Plans Accepted Date: ____________________ By:__________________________________

Comments/Conditions_________________________________________________________________________

____________________________________________________________________________________________ ONCE THIS APPLICATION IS APPROVED, NO CHANGES MAY BE MADE WITHOUT CCHD REVIEW AND APPROVAL.

Plans Disapproved Date: ____________________ By: __________________________________

Reason: _____________________________________________________________________________________

DETAILS OF PROPOSED FOOD SERVICE SERVICE TYPE

Table service only Yes___ No___ “Take out” service Yes___ No___ Food delivery Yes___ No___ Off-site catering/food handling Yes___ No___ Car hops Yes___ No___ Self Service Salad Bar or Buffet Yes___ No___ Frozen desserts/soft ice cream Yes___ No___ Vacuum packaging Yes___ No___ Other (explain)

VENTILATION / EXHAUST Kitchen Exhaust hoods: Yes___ No___ Hood opening: (square feet) ____________ Fan capacity: ____________(C.F.M.) Provided with filters: Yes___ No___ Provided with automatic fire protection: Yes___ No___ Restroom exhaust fans: Yes___ No___ Seating capacity ____ Maximum Fire Code Occupancy ____

COLD STORAGE Location Type Size

HOT HOLDING EQUIPMENT Location Type Size

DISH AND UTENSIL WASHING FACILITIES Dishwasher: Heat__ or Chemical___ NSF approved: YES __ NO __ Company/Model #________________ 3- Bay sink wash system location______ Size of smallest bay (L x W x D) ____________ Dirty dish storage and drain boards location__________________

Hot Water Heater Storage capacity (Gallons) _____________ Washer and Dryer ___ or Linen Service____

SINKS / HANDWASHING Location Size (L x W x D)

Food Preparation Sink w/indirect drain ___x___x___ Utility /Mop Sink ___x___x___ Hand Wash Sink

SURFACE MATERIALS CEILINGS FLOORS WALLS

Serving Area Kitchen Area Dining Area Bar Dry Storage Area Toilet Area Dressing Room Ware Washing Area Walk-in refrigerators/freezers Food prep surface(s) Cutting boards

PERSONNEL How many food handlers, including yourself if applicable, will there be per shift? ___________ per day?___________ How will food handling and safety responsibilities be divided? (i.e., 1 cook, 2 wait staff, 1 dishwasher, etc.) per shift?

MENU Attach a copy of the menu and fill in below: FOOD CATEGORIES (check all that apply):

� Thick Meats (roasts, poultry, ham, etc.)� Cook and Serve Food (meat/burgers, fish, eggs, etc.)� Shellfish� Soups, Chowders, Stews, Casseroles, and Rice� Cold Vegetables, Cold Salads and Sandwiches� Baked Goods� Frozen desserts/soft ice cream

Breakfast Menu Items: _____________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Prep. Time: _________________ am / pm

Lunch Menu Items: _________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Prep. Time: _________________ am / pm

Dinner Menu Items: ________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________

Prep. Time: _________________ am / pm

THERMOMETERS Thermometers: Number of food probe thermometers:___________________ Number of ambient (refrigeration) thermometers:______

SANITATION Method of garbage storage and disposal:

� Number of indoor containers____________� Size of indoor containers ____________� Location of indoor containers ____________(show on drawings)� Frequency of emptying indoor containers____________� Number of outdoor containers____________� Location of outdoor containers____________(show on drawings)� Frequency of emptying outdoor containers____________� Waste removal company____________

Storage location of workers personal items: Storage location of chemicals/cleaning products: Sneeze guards or other protection for self-serve food: Explain____________________________

Number of Restrooms: Employee ___ Public____ Grease Trap Type: Interior ___ Exterior___ Size(gallons)_____ Location:____________ No Grease Trap___ Sanitizer Chemical(s) to be used:_________________________ Container type________________________ Type of Test Strips___________________

Lighting (check all that apply) � At least 30 foot candles on food preparation surfaces� At least 20 foot candles in utensil and equipment storage areas� At least 20 foot candles in toilet areas� At least 20 foot candles in walk in refrigeration and dry food storage� At least 20 foot candles in dining area when cleaning and other areas� Shielded where required

Methods of insect and rodent control: (Check all that apply)

� All windows screened� Rest room doors self-closing� Exterior doors self closing� Exterior doors remain closed unless screened� Daily cleaning

(explain)__________________________________________________________� Food storage

(explain)___________________________________________________________� All trash/garbage containers have covers� Licensed pest control service� Other

__________________________________________________________________________

BEVERAGES Type of beverages served: (check all that apply)

� Bottled beverages� Canned beverages� Made onsite beverages__________________________________� Post mix soft drinks (has water inlet connection)� Pre-mixed soft drinks system – (has no water connection)� Coffee maker with inlet water line� Coffee maker – pour in� Other (explain)___________________________________________

Location of backflow device (post mix system) State location of beverage storage and/or system (show on floor plan):

FOOD SERVICE – EXAMPLE- SCHEDULE OF EQUIPMENT

Item #

Description

1 STORAGE SHELVING

2 AIR CURTAIN

3 EMPLOYEE LOCKERS

4 2 DOOR REACH IN FREEZER

5 FLOOR DRAIN 6 MOP SINK 7 3-BAY SINK 8 DRAIN BOARD 9 FOOD PREP SINK

10 STAINLESS STEEL WORK TABLE 11 HAND WASH SINK 12 WALK-IN COOLER 13 SHELVING (COOLER) 14 MICROWAVE 15 COUNTER 16 STEAM TABLE 17 TRASH CAN 18 HOT WATER TANK 19 FRYER 20 GRILL 21 4-BURNER STOVE 22 EXHAUST HOOD 23 DISHWASHER 24 REFRIGERATOR 25 CLEANING PRODUCTS STORAGE

FOOD SERVICE ESTABLISHMENT NOT ON PUBLIC SEWAGE

• If you intend to use an existing sewage treatment system, you must complete this form below so the CCHD can determine whether or not your proposed sewage treatment system is a new or replacement system.

• If a new system is intended, you must hire a New York State Licensed Engineer to design your sewage treatment system. All new systems must meet all the requirements of the Clinton County Sanitary Code, Article IX, Section 4; and NYSDEC Bulletin, Design Standards for Wastewater Treatment Works. You must do one of the following: A) If your Food Service Establishment produces more than 1,000 gallons of wastewater per day, you need to contact DEC at (518) 897-1200 for a SPDES Permit Application; or B) If your Food Service produces less than 1,000 gallons of wastewater per day, you need to continue with the following instructions.

• All sewage treatment system engineering plans for new or replacement systems must be reviewed and approved by CCHD prior to the system being installed. A CCHD representative must witness the deephole and percolation tests.

• Once installed, your design engineer must submit a “Letter of Completed Works” to CCHD certifying that the system was installed in accordance the approved plan prior to you using the sewage treatment system. CCHD RESERVES THE RIGHT TO DO A FINAL INSPECTION OF THE SEWAGE TREATMENT SYSTEM.

NEW SEWAGE TREATMENT SYSTEM YES NO

New construction on previously undeveloped property?

New Certificate of Occupancy required by Town?

Change in Size or Intended Usage: A) Change from residential use to commercial use

B) Addition of more seating, or increased water usage

C) Seasonal dwelling converted to year-round use

Has lot been unoccupied for 5 years or more?

REPLACEMENT SEWAGE TREATMENT SYSTEM YES NO

Prior System: A) Was there a previous septic system installed on

this lot?

B) Has it been in use for the past 5 years?

C) Was it approved by the Clinton County Health Department?

Occupancy: A) Has lot been continuously occupied to present? (Town Codes Officer can

verify)

B) Prior Certificate of Occupancy granted by Town Codes Officer?

Year structure was built/ structure placed on lot _________________ Year prior sewage system was installed ________________________

OWNER: CCHD REPRESENTATIVE:

X _____________________________________ X _________________________________

DATE: _______________________________ DATE: _______________________________

HEALTH DEPARTMENT USE ONLY

Based on the above criteria, the IST system is: NEW REPLACEMENT (CIRCLE ONE)

INSTRUCTIONS FOR FACILITY BASIC DATA FORM

A. General

Items 1-4 This information must be consistent with Who and where are you? the permit application.

Detailed Location and Provide a reproduction of a section of a Sketch (Items 5-6) highway map or a detailed drawing. The How do we get there? narrative section should be completed to

supplement the sketch. Item 7 Sign and Date the form

B. Water Supply

1. Type of Water Supply Check the appropriate box. If a Public CWS- Community Water System Water Supply is the source, write in the Private – Water system is name of the system and do not complete the for your food service only remainder of the section, unless other

sources serve the facility or are available.

2. Sources Indicate the number of wells, springs, etc.

3-5. Non potable sources Answer as indicated.

6. Schematic Draw a simplified flow diagram showing the pump, treatment equipment, storage tanks, water heaters, connection to distribution system, etc. Drawings, while not to scale should be accurate and reflect the sequence and indicate how all sources connect to the system.

C. Sewage Treatment

1. Type If the facility is connected to a municipal system, indicate the name of the system and do not complete the remainder of this section unless on-site systems also exist.

2-3. Complete as indicated.

4. Schematic A flow schematic showing major components in the system in the sequence they are installed. Indicate capacities, sizes, lengths, etc. where appropriate.

D. Property Layout Sketch Show: All buildings associated with the food service, property lines, location of garbage storage, location of water supply into buildings and sewage treatment system components out of all buildings, roads, parking and drive/walkways.

FACILITY BASIC DATA A. GENERAL INFORMATION

6. Location

1. Facility Name _____________________________

2. Facility Type _____________________________

3. Street Address ____________________________

4. T, V, C ___________________________________

5. Directions to Facility __________________________________________________________________ ______________________________________________ ______________________________________________

7. Completed by __________________________ Date __/__/__ Updated on __/__/__ Initials ____

B. WATER SUPPLY INFORMATION

1. Type of Water Supply Community Water Supply (Name)___________________________ Private

2. Sources (specify number by source) ___ Wells ___ Springs ___ Surface Supplies

3. Disinfection Provided YES NO

4. Disinfection Method CHLORINATION ULTRA VIOLET LIGHT

5. Are there any non-potable water supplies? YES NO (If no, go to number 6)

a. How is the non-potable water used? _________________________________________

b. Are they connected to the potable supply? YES NO

c. What type of backflow protection is provided? _____________________________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

-8-

6. Water Supply Schematic

C.SEWAGE TREATMENT INFORMATION

1. Type On-site Municipal (Name) ___________________________ (Complete items 2, 3 and 4 only if private system is in use)

2. SPDES Permit required? Water usage > 1,000 gallons /day YES NO

3. Specify the major components of the system in use ________________________________ _________________________________________________________________________________

D. PROPERTY LAYOUT SKETCH (each square represents 10 ft. x 10 ft.)

4. Sewage Treatment Schematic

TEMPORARY FOOD SERVICE SUPPLEMENT (1 of 3) 1. Name of Booth: ______________________ Contact's name/phone/email: _______________________________________

____________________________________________________________________________________________________ 2. Event: _____________________________ Event Coordinator: ____________________________

Event Location: ________________________ City: _____________________ZIP: ______________ Event Dates: ____________________ Event Hours: __________________ Is this your first time at this event? Yes___ No___ Greatest number of people to be served____________ How many food workers/handlers at the event__________

3. Prep Kitchen. All advance food preparation and storage must be done in an approved kitchen facility. No home storage orpreparation of food is allowed. Indicate below where food will be stored and/or prepared

Kitchen Name: _____________________________ Contact Person: __________________________

ATTACH SIGNED COPY OF “Use of Commissary/Shared Kitchen Agreement” (page 23)

4. MENU and PREPARATION PROCEDURES:I. Check all food preparation procedures that will be done in advance at the COMMISSARY

FOOD Include beverages and condiments

Pre

p d

ate

Thaw

Cut/

A

ssem

ble

Cook/

bake

Cool

Cold

H

old

ing

Rehe

at

Hot

Hold

ing

Port

ion/

Package

Sto

rage

Critical Control Points NOTES

a. b. c. d. e. f. g. h.

II. Check food preparation procedures that will be done at the EVENT:

FOOD Include beverages and condiments

Pre

p d

ate

Assem

ble

Cook/

bake

Cold

H

old

ing

Rehe

at

Hot

Hold

ing

Port

ion/

Package

Critical Control Points NOTES

i. j. k. l. m. n. o. p.

NOTE: Use a separate sheet of paper if you are unable to fit all of your menu items onto this form.

Comments__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

**ALL 3 PAGES MUST BE SUBMITTED EVERY YEAR WITH YOUR PERMIT RENEWAL**

TEMPORARY FOOD SERVICE SUPPLEMENT (2 of 3) Name of Booth____________________________

5. Keep Foods Hot or Cold. Potentially hazardous food must be at 45 ̊ F or below, or 140 ̊ F or greater.Check equipment that will be used. Cold Holding: � refrigerator � refrigerated truck � ice/cooler � dry ice/cooler � drained ice � other:______________

Cooking, Hot Holding or Reheating: � hot case �oven �BBQ �gas grill �wok �steamer �stove �steam table� other:_____________

6. Booth. Overhead cover must protect the interior of the booth from dirt and weather. Floors should be a cleanable material,not grass or dirt. All food, utensils, and paper products must be stored off the floor. All activity and food storage must fit inside the booth. Specify floor material ____________________________________________________

7. ADDITIONAL REQUIREMENTS CHECKLIST:� No Bare Hand Contact with Ready-To-Eat Foods- Use barriers like tongs, bakery papers or gloves. Workers with

symptoms of diarrhea, vomiting, jaundice, or sore throat with a fever cannot work.� Sanitizer - Provide sanitizer solution for wiping cloths. Mix one teaspoon of chlorine bleach per gallon of water.� Thermometer - A properly calibrated metal stem probe thermometer is required. Check temperatures of potentially

hazardous food frequently.� Sneeze Guard - Foods prepared, cooked or displayed on the front counter must be protected with a sneeze guard.� Permit to Operate - Have your permit displayed in the booth where the public can see it.� Leftovers - Hot food must be discarded at the end of the day. Cooling of food at the event or in the booth is not allowed.� Waste Water- Pour wastewater into a sanitary sewer. Do not discharge waste water into storm drains or on the ground.� Employee Restrooms- Provide access restrooms for your employees. Restrooms must have hand sinks with hot and

cold running water. Wash hands before returning to the booth. Portable toilets are not allowed, unless portable handwashing facilities with hot water, soap and paper towels are provided.

� Dish Washing - For one day events, bring extra utensils and food equipment to change out as needed. Provideplumbed dishwashing facilities if the event is more than one day. Soap, sanitizer, and sink drain plugs must also beprovided. Dish tubs are not acceptable

� Insect Exclusion – All foods kept covered at all times unless in a screened booth.� Hand Washing - Provide a gravity flow hand washing facility in your booth.. Check the hand wash facilities throughout

the day and refill when needed. WASH HANDS FREQUENTLY!

Temporary Food Hand Wash Set Up Example:

Typical Components: � Table

� 5-Gallon insulated container with warm water and spigot to allow the flow of

water without having to hold it;

� 5-Gallon waste bucket to receive the wash water

� Hand Soap

� Paper Towels

YOUR APPLICATION MUST BE RECEIVED AT LEAST 30 DAYS PRIOR TO THE EVENT. APPLICATIONS RECEIVED LESS THAN 30 DAYS PRIOR TO THE EVENT MAY BE CHARGED AN ADDITIONAL FEE AND/OR

THE MENU MAY BE RESTRICTED. **ALL 3 PAGES MUST BE SUBMITTED EVERY YEAR WITH YOUR PERMIT RENEWAL**

TEMPORARY FOOD SERVICE SUPPLEMENT (3 of 3) Provide a layout drawing to scale in the space below. The following items must be shown and labeled:

�Sanitizer containers �Ice containers �Dry Goods Storage �Food Handling Surfaces �Cooking Equipment�Hot Holding Equipment �Cold Holding Equipment �Hand Washing �Utensil Washing �Garbage Storage

LAYOUT (each square represents 1 foot x 1 foot)

**ALL 3 PAGES MUST BE SUBMITTED EVERY YEAR WITH YOUR PERMIT RENEWAL**

MOBILE FOOD SERVICE ESTABLISHMENT DETAILS Will you perform catering? YES_____ NO_____ ( If yes, you must complete and submit page 22)

Type of Event & Locations___________________________________

Explain all sources of fuel & power usage_____________________________________________________________________

_____________________________________________________________________________________________________

POTABLE WATER SUPPLY TANK: Volume_________ gallons. Minimum is 40 gallons; if less, give

explanation:____________________________________________________________________________________________

WASTEWATER TANK: Volume___________ gallons. Must be a minimum of 15% greater than potable water tank.

Location & method of wastewater disposal:___________________________________________________________________ HOT WATER HEATER: Volume_________ gallons. Explain methods of sanitizing food contact surfaces________________

____________________________________________________________________________________________________

Location of workers’ personal items:_________________________________________________________________________

State all other equipment and/or vehicles used:________________________________________________________________

_____________________________________________________________________________________________________

How many food handlers are needed when the unit is at full production? _________________________How many food handlers can your unit hold?________________________________________________

How will food handling and safety responsibilities be divided? i.e. 2 prep cooks, 1 grill cook, 1 fryer cook, 1 order person and 1 cashier:____________________________________________________________

� Declare ALL FOODS to be served (including beverages). If not declared in this review, it cannot be served.Clinton County Health Department will limit menu volume to your unit’s capacity. Be prepared to show youhave the equipment and the area to produce your intended menu.

Food Items by Category

Source Storage Handling How? What?

Critical Control Points Criteria

Name Condition Location Volume Cooking Hot

Holding

Preparation

7. Where is dormant storage of unit?___________________________________________________________

Method of rodent control during dormant storage of unit:__________________________________

MOBILE FOOD SERVICE ESTABLISHMENT LAYOUT FOR: _______________________________________________

( Mobile FSE Name as Stated on Permit Application)

Left Side from inside: To show over-under orientation of equipment & storage

Roof

Back Front

Floor

Top View Through Roof: To show areas and equipment orientation

Left Side

Back Hitch or cab area

Right Side

Right Side from Outside Through Wall: To show over-under orientation of equipment & storage

Roof

Back Front

Floor

MOBILE FOOD SERVICE ESTABLISHMENT PLUMBING AND DISINFECTION PROCEDURES

FOR:____________________________________________

(Mobile FSE Name as Stated on Permit Application)

Provide a diagram below showing ALL plumbing include: hoses; pipes; inlet connections; check valves; shut-off valves; filters; pumps; tanks (hot, cold & waste); drains; and wastewater connections.

Explanation of water system disinfection procedures:_______________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Frequency__________________________________________________

CCHD Review Comments:_____________________________________________________________

_____________________________________________________________________________________________________

_______________________________________________________________

OFF-SITE CATERING PLAN REQUIREMENTS

FOR: ____________________________________________________ (Name of Facility)

Type of Event(s): Greatest number of people to be served( ) Will service be: County-wide[ ] or limited[ ] Length of service: Less than one hour [ ] Over one hour [ ] If over one hour, how long ( )Will dish and tableware be single-use/disposable[ ] or washable [ ] If washable, how many place settings: Number of disposable food service gloves brought to an event:( ) Garbage handling containers and method of disposal: Will any of the following be done at the catered site:

• Cooking: YES / NO If yes, explain

• Hot-holding: YES / NO If yes, explain

• Cold-holding: YES / NO If yes, explain

• Self-Service or Buffet: YES / NO If yes, explain

• Potentially hazardous foods served: YES / NO If yes, explain

Will any menu item(s) be prepared before the event requiring cooling and then re-heating on the day of service: YES / NO If yes, explain

Minimum number of food handlers needed for transport, service, breakdown and clean-up is ( ) State all critical control point (CCP) monitoring responsibilities by job title. For help identifying CCP’s http://www.clintonhealth.org/forms/haccp.pdf

Site Evaluation & Preparation - Attach a typed explanation of how you will ensure the catered site will have necessary facilities for achieving critical control points and food handlers’ hygiene; such as potable water, wastewater disposal, electric power, work area, restrooms and hand washing, etc. (Label this attachment “Name of Your Facility – Offsite Catering Plan ATTACHMENT #1”) Transportation- Attach a typed explanation of vehicle(s) type and cargo space. Provide enough details to indicate that conditions are sufficient for cleaning, excluding vermin, and able to achieve CCP’s. Photographs are not required however they are encouraged (Label this attachment “Name of Your Facility – Offsite Catering Plan ATTACHMENT #2”)

Hand Wash Station (HWS)- Attach a diagram or picture of your self-contained HWS to be used on-site or explain under “Site Evaluation & Preparation” the requirement of an already plumbed HWS to be provided by client and verified in a pre-event evaluation. (Label this attachment “Name of Your Facility – Offsite Catering Plan ATTACHMENT #3”) List of Equipment – Attach a typed list of all equipment transported to the catered site to be used for achieving CCP’s. Categorize by cookware, utensils, food containers, ice containers, cooking, refrigeration and any other items needed on site. Photographs are not required however they are encouraged (Label this attachment “Name of Your Facility – Offsite Catering Plan ATTACHMENT #4”)

USE OF COMMISSARY/SHARED KITCHEN AGREEMENT All Food Establishments must operate out of an approved facility located within Clinton County. Many food operations such as Mobile Food Units and Caterers utilize commissaries that are not under their own ownership. This form shall be completed if you are not the owner of the commissary or if you will be sharing kitchen facilities with other vendors

The commissary must have facilities for supply storage, equipment cleaning, food preparation and other servicing activities. Minimum plumbing requirements for a commissary include a 3-compartment sink, a mop sink for dumping waste water, and a hand wash sink. An indirectly drained food preparation sink will be required if produce washing occurs as part of the preparation activity. Plan/Permit approval is contingent upon thorough documentation of the servicing activities to be performed at the commissary. Provide scale drawings of the commissary kitchen showing the food service equipment and storage to be used. (All of these items must be addressed as incomplete plan submittals may delay approval.) Indicate which of the following services will be allowed for use at the commissary:

� 3-Compartment Sink� Food Prep Sink� Dry Storage Space (Linear square feet)� Restroom Access� Key Accessibility to Commissary (if necessary)� Preparation Table/Equipment� Off Street Parking for trucks/trailers

� Hand Wash Sink� Commercial Refrigeration Space� Freezer Space� lce Machine� Cooking Equipment� Mop Sink� Other:________________

Commissarv Information: Name of Business:_______________________________________ Address: _________________________________________City:_______________________ Zip________________Contact Person:_________________________________________Title:_______________________ Email: _______________________Phone:________________________________Business Hours of Operation_____________________________________ Do other vendors use this commissary? � Yes � No lf so, how many___________

Mobile Unit/Caterer/Vendor Information: Name of Business:_______________________________ Owner/Operator_____________________________Title:________________________________ Email: __________________________Phone:___________________________________ Address:__________________________ City:_____________________________________ Days/Time at Commissary:______________________________________

_________________________________________ ________________________________________ (Commissary Owner/Agent - Printed Name & Title) (Mobile Unit/Caterer/Vendor- Printed Name & Title)

_________________________________________ ________________________________________ (Commissary Owner/Agent - Signature & Date) (Mobile Unit/Caterer/Vendor- Signature & Date)

This agreement between the owner of the commissary and the operator of the mobile unit, caterer or vendor signifies that both parties agree to the allowed use of the commissary as specified. Note that this agreement is not transferable. Should there be a change in ownership of either the commissary or mobile unit caterer/vendor, or should there be any modification or cancelation of this agreement between parties, then the Clinton County Mobile/Caterer/Vendor Food Service Establishment Permit may be suspended.

For Office Use Only: Health Department approval for use of commissary by the mobile food unit owner/vendor identified above:

________ ___________________ ___________________________ (Date) (Printed Name) (Signature)

THIS PAGE INTENTIONALLY LEFT BLANK

NEW YORK STATE DEPARTMENT OF HEALTH Application for a Permit to Operate Bureau of Community Environmental Health and Food Protection

GENERAL INSTRUCTIONS

Complete all items that apply to your establishment. All applicants must complete sections A, B, G, & H. lf you have any questions, contact the local health department that issues your permit.

Section A. Facility Information

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 total number of tanning devices.

Facility Status: Check either profit or nonprofit. lf nonprofit, submission of documentation (incorporation paper) verifying status may be required.

Facility Type: From the list 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 Types; Agricultural Fairgrounds Bathing Beaches

Freshwater River Impoundment/Pond Lake Ocean Surf Other Saltwater

Campground/Recreational Vehicle Park Children's Camps Day Camp Day Camp - Developmentally Disabled

Day Camp - Municipal Day Camp - Traveling Overnight Camp

Overnight Camp - Developmentally Disabled

Overnight Camp - Municipal Food Service Establishment

Restaurant Caterer School lnstitution 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

Mass Gathering Migrant Farm Worker Housing

Farm Labor Housing Mobile Home Parks Mobile Food Recreational Aquatic Spray Grounds

Indoor Outdoor

Swimming Pools lndoor Outdoor lndoor/Outdoor Wave Pool - lndoor Wave Pool - Outdoor Wave Pool - lndoor/Outdoor Aquatic Amusement - lndoor Aquatic Amusement - Outdoor Aquatic Amusement - lndoor/Outdoor Spa

Tanning Facility Temporary Food

Temporary Residences Labor Camps other than Migrant lnterior Corridor - Single Story

lnterior Corridor - Two Story

lnterior Corridor - Three Story

lnterior Corridor - Four or more StoryExterior Corridor - Single Story

Exterior Corridor - Two Story

Exterior Corridor - Three Story Exterior Corridor - Four or more Story

Vending Food Machines State Agency Licensed Facilities

State Licensed Inspected Facility State Owned Operated Facility

Day Care Center - Residential Day Care Center - Non-Residential

Water Supply/Sewage System: Check "public" if the facility is serviced by a municipal or public system. Check "private" (onsite) if the system(s) and its operation is onsite and only for this facility. A water/sewage system that is commonly used by several establishments (i.e.: a mall operation) would be a public system.

Operations under this registration: Provide the number of specific operations that apply to this registration. Complete even if the primary or main operation of the facility was identified under the facility type. A swimming complex with one spa, one beach, one indoor and two outdoor pools would report a facility type swimming pool-indoor and enter 1 for spa, 1 for bathing beach, 1 for indoor pool and 2 for outdoor pools in the operations under this registration Section A. For tanning facilities enter the number of beds and booths. Some facilities with multiple operations require separate applications, (i.e., a food service operated at a swimming pool complex would require a separate swimming pool and food service application, and would report their specific operations on the appropriate application forms).

Expected Opening/Closing Date: Enter the expected opening and closing dates (i.e., June 1 is 06/01). lf the operation is year-round, enter 01/01 for opening and 12/31 for closing.

Days of Operation: Check each box for the day(s) the facility will be open under routine operation.

Hours of Operation: Enter the hour the facility is expected to open and close under routine operation. Circle AM or PM as appropriate.

SECTION B: Operator/Owner Information

Name of Legal Operator or Operating Corporation (Person in Charge): Enter name of the legal entity that operates the facility. lf the facility is operated by a corporation, enter the name of the operating corporation and the name of the person in charge of the day to day operation. Provide the name(s) of the corporate officers/partners in Section F.

Permanent Address of Operator and Telephone Number: Enter the mailing address including street, city, state and zip code where the legal operator wants to receive mailed correspondence. Enter the telephone and fax number of the legal operator.

Employer Identification Number: Enter the Employer Identification of the operator of the facility.

Email Address and Fax No.: Enter the email address and fax no. where important health and safety alert messages should be sent during an emergency.

Name of Owner: Enter the name of the owner of the facility if different from the operator.

Permanent Address of Owner and Telephone Number: Enter the mailing address and telephone number of the owner if different from the operator.

SECTION G: Complete only for temporary food service establishments, regulated under Subpart 14-2 NYSSC

SECTION D: Complete only for mobile food service vehicles or pushcarts, regulated under Subpart 144 NYSSC

Check the appropriate type of unit. lf motorized, provide the license plate number. Provide the name and address of the commissary where the food is prepared. Attach a separate list of the types of food(s) and/or beverages to be served.

SECTION E: Complete only for food/beverage vending machines, regulated under Subpart 14-5 NYSSC

Attach a list of the number and type of food dispensing machines including the address and telephone number of each site under this permit.

SECTION F: Partners and Corporation Officers

lf a facility is operated by a partnership or corporation, provide the name, title, permanent mailing address and telephone number of all corporate officers or partners involved in the operation or ownership of the facility

SECTION G: Workers' Compensation and Disability Insurance

Provide copies of appropriate forms documenting compliance with the Worker's Compensation Law for ('1 ) both Workers' Compensation and New York State Disability Insurance coverage, or (2) exemption from coverage.

SECTION H: Signature

Provide the signature of the individual operator, a corporate officer or other authorized identified official in Section F. Please print the name, title and date in the space provided. Failure to sign the form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code and is punishable by fines.

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection

Complete all items that apply to your establishment (all applicants must complete Sections A, B, G and H), sign on the back page and return with the appropriate fee at least 30 days prior to the expected opening date to:

Clinton County Health Department 135 Margaret St. Plattsburgh, NY 12901 518-565-4870

SECTION A: Facility Information (Entire section must be completed by all applicants.)

Facility name____________________________________________________________________________________

Facility address_________________________________________________________________________________

City____________________________________________________________

State ____ Zip______________ Telephone no. ( ) _____________ Fax no. ( )______________

Municipality _________________[T] [V] [C] Capacity[______] Facility Status [ ] Profit [ ] Non-profit

Facility Type [___________________________________]

Days /hours of operation____________________________________________________________________________________________

________________________________________________________________________________________________________________

Water Supply [ ] Public (municipal)

[ ] Private (onsite)

Sewage System

[ ] Public (municipal)

[ ] Private (onsite)

Number of operations under this registration [ ] Indoor Pools [ ] Bathing Beaches [ ]Food Services [ ]Day Camps

[ ]Outdoor Pools [ ]Spa Pools [ ]Recreational Aquatic Spray Grounds

[ ]Tanning Devices

SECTION B: Operator/Owner Information (Entire section must be completed by all applicants.)

Legal operator or operating corporation_____________________________________________________________________ (if corporation or partnership, Section F must be completed.)

Person in charge____________________________ Telephone no. ( ) _____________ Fax no. ( )________________

Permanent address___________________________________ Email address_____________________________________

City______________________ State____ Zip____ Employer Identification Number (EIN)_____________________________

Owner________________________________________ Telephone no. ( ) _____________

Permanent address _______________________City__________________ State ____Zip________

SECTION C: Complete for temporary food service establishments only (attach additional sheets as necessary).

Name and location of event_____________________________________________________________________________________

Name of Foods Supplier of ingredients Where and how foods will be prepared and served

Application for a Permit to Operate

SECTION D: Complete for mobile food service establishments or pushcarts only.

Type of vehicle [ ] Motorized [ ] Pushcart [ ] Other (specify)______________________________________________

Motor vehicle license number (motorized vehicles only)_______________________________________________________________

Commissary name_______________________________________ Telephone no. ( ) ____________________________________

Address____________________________________ City_______________________________ State______ Zip________________

List on a separate sheet of paper the type of food and beverages served

SECTION E: Food and beverage machines only. Attach a list of all machine locations and food dispensed

SECTION F: Partners and Corporate Officers

List all partners and corporate officers in the operation of the facility. Include vice president(s), secretary, treasurer. Attach DOH-2135 (or additional sheets) as necessary.

Name Title Address Telephone No.

SECTION G: Workers' Compensation and Disability Insurance (All applicants must complete this section.)

Check the appropriate lines and submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law: A. Workers Compensation and Disability Insurance Coverage Provided Workers Compensation [ ] Form C-105.2 - Certificate of Worker's Compensation Insurance OR [ ] Form U-26.3 - Certificate of Workers' Compensation Insurance OR [ ] FormSl-12 - Certificate of Workers' Compensation Self-Insurance OR [ ] GSI - 105.2 - Certificate of Participation in Workers' Compensation Group Self-Insurance

AND

Disability Insurance [ ] DB-120.1 - Certificate of Disability Benefits OR [ ] Form DB-155 - Certificate of Disability Benefits Self-Insurance

B. Workers Compensation and Disability Insurance Coverage NOT Provided [ ] Form CE-200 - Certifìcate of Attestation of Exemption from NYS Workers' Compensation and/or Disability Benefits Coverage

SECTION H: Signature (Entire section must be completed by all applicants.)

FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW. Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code. Signature of individual operator or authorized official__________________________________________________________________

Print name of person signing____________________________________________Title_______________________ Date__________

SECTION l: FOR OFFICE USE ONLY

Permit issuance recommended? [ ]Yes [ ]No Permit Effective Date [ ] [ ] [ ] Permit Expiration Date [ ] [ ] [ ] Conditions of approval

Signature__________________________________________________________ Title_______________________ Date__________

**IMPORTANT**

IF YOUR FACILITY IS OWNED/OPERATED BY A CORPORATION, A DULY AUTHORIZED OFFICER OR

REPRESENTATIVE OF THE CORPORATION MUST SUBMIT A CERTIFIED COPY OF A RESOLUTION OF THE BOARD OF DIRECTORS OF THE CORPORATION, AUTHORIZING THE MAKING OF AN APPLICATION TO

OPERATE.

ATTACHED, ON THE WHITE SHEET, IS AN EXAMPLE OF A CERTIFIED COPY OF A RESOLUTION. YOU MAY FILL IN THE BLANKS ON THIS SHEET, OR SUBMIT YOUR OWN COPY.

Be it known……

A meeting of the corporation of _____________________________, (Name of Corporation)

__________________________, was held for the purpose of (City & State)

authorizing renewal of a Department of Health Permit to Operate.

_____________________ motioned to authorize and (Name)

_____________________ seconded the motion to authorize pursuit (Name)

of a permit to operate from the Clinton County Health Department.

Motion was passed unanimously by corporation officers/partners

present.

Signed: ____________________________________________

Dated:______________________________________________

CORPORATION OFFICER & PARTNER FORM

CLINTON COUNTY HEALTH DEPARTMENT 133 Margaret Street

Plattsburgh, NY 12901 phone: (518) 565-4870 Fax: (518) 565-4843

www.clintonhealth.org

NAME OF FACILITY________________________________________________________________

NAME OF CORPORATION__________________________________________________________

INSTRUCTIONS: This form must be completed for all Clinton County Health Department regulated facilities operated and/or owned by a corporation, limited liability company (LLC) or partnership. One form must be completed for each corporation, LLC or partnership involved in the operation or ownership of the facility. This form must be completed and submitted every year or each time there is a change in officers or partners.

NAME TITLE PERMANENT MAILING ADDRESS

Are any of the officers or partners presently involved in the operation or ownership of any other facility regulated by the NYS or the Clinton County Sanitary Code?

□ Yes □ No If yes, please list the name(s) and the facility(ies) below: NAME FACILITY FACILITY ADDRESS

ATTACH ADDITIONAL SHEETS TO CONTINUE LISTINGS

Are you registered with the Clinton County Clerk’s Office or the NYS Department of State? Yes No

Date Completed________________________ Name of Preparer_______________________

Telephone Number______________________ Signature______________________________

INFORMATION REGARDING CORPORATION OFFICER AND PARTNER FORM

***IMPORTANT*** If your facility receives an operating permit from the Clinton County Health Department and your

facility is owned/operated by a corporation, LLC or partnership, a duly authorized officer or representative must submit a certified copy of a resolution of the board of directors of the

corporation, LLC or partnership authorizing the making of an application to operate.

If your facility is owned and/or operated by a corporation, LLC or a partnership (more than one person, excluding husband and wife), all officers, titles and addresses must be listed on the reverse of this form.

If your facility is issued a Clinton County Health Department Permit, a permit will not be issued for any corporation, LLC or partnership unless all officers/partners are listed.

CORPORATIONS If you are operating under a corporation name, you must be registered with the NYS Department of State regardless of whether your corporation is registered in another state. Please contact the NYS Division of Corporation and State Records, 162 Washington Avenue, Albany, NY 12231 (518) 473-2492.

The New York Department of State will notify the Clinton County Clerk of all registered Corporations.

PARTNERSHIPS For facilities operating as a partnership, you must have a DBA (Doing Business As) Partners Certificate. This must be on file with the Clinton County Clerk’s Office.

DBA FOR INDIVIDUALS If you operate your facility under a business name or an assumed name (i.e., Jim’s Tavern, Jim’s Pool, etc…..) and not as a corporation, LLC or partnership, you are required to have a DBA Individual’s Certificate on file with the Clinton County Clerk. The Clinton County Clerk’s address is: 137 Margaret Street Plattsburgh, NY 12901 (518) 565-4700

PLEASE NOTE: All Corporations, LLCs, partnerships, or DBA Individual Certificates must be registered with the appropriate agency as outlined in Article 9B, Section 130 of the NYS General Business Law. It is a misdemeanor for persons to carry on, conduct, or transact businesses who knowingly fail to comply with Section 130.

It is your responsibility to register your facility with the appropriate agency.

Required Workers’ Compensation and Disability Insurance Forms Instructions To learn what required Workers’ Compensation and Disability Insurance Forms that you need to submit with your permit application, please, go to the following web address:

http://www.wcb.ny.gov/content/main/Employers/Employers.jsp

Now look up the required form on the website, and follow the instructions.

Workers’ Compensation Forms

Form Number

Form Title Who Files Where to File When to File

C-105.2

Certificate of NYS Workers' Compensation Insurance Coverage (All private NYS licensed workers' compensation carriers are required to issue the C-105.2. Please note that the

State Insurance Fund issues a different form, the U-26.3 form, as its version of the C-105.2)

Employers insured for workers'

compensation through a private insurance

carrier

Filed with the government agency issuing a permit, license or

contract. The C-105.2 must be completed by the insurance

carrier or its licensed insurance agent.

Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form from their private

insurance carrier. Carriers and their licensed agents may contact the Board's Bureau of Compliance to obtain this form.

U-26.3

NY State Insurance Fund Certificate of Workers' Compensation Coverage (This is the State Insurance Fund's equivalent of Workers'

Compensation Board Form C-105.2)

Employers insured for workers'

compensation through the State Insurance

Fund


contract.

Upon obtaining a permit, license or contract from a government agency. Employers

must obtain this form from the State Insurance Fund.

SI-12 Affidavit Certifying That Compensation Has

Been Secured

Employers with Board-approved self-insurance for workers'

compensation

Filed with the government agency issuing a permit, license or contract. The SI-12 must be

completed by the Board's Self-Insurance Office and approved by

the Board's Secretary.

Upon obtaining a permit, license or contract from a government agency. Board-

approved self-insurers must obtain this form from Board's Self-Insurance Office.

(518) 402-0247

I-105.2 Certificate of Participation in Workers'

Compensation Group Board-approved self-insurance

Employers participating in group

self-insurance for workers'

compensation


contract. The GSI-105.2 must be completed by the group self-

insurance administrator.

Upon obtaining a permit, license or contract from a government agency. Employers

must obtain this form from their group self-insurance administrator. For further information contact the Board's Self-Insurance Office at (518) 402-0247.

Disability Insurance Forms

Form Number Form Title Who Files Where to File When to File

DB-120.1

Certificate Of Insurance Coverage

Under The NYS Disability Benefits

Law

Employers insured for NYS statutory

disability benefits insurance through an

insurance carrier.

Filed with the government agency issuing a permit, license or contract. The DB-120.1 must be completed by either

the NYS statutory disability benefits insurance carrier, or a licensed NYS

insurance agent of that carrier.

Upon obtaining a permit, license or contract from a government agency. Employers must obtain this form

from either their NYS statutory disability benefits insurance carrier or a licensed NYS insurance agent of

that carrier. Carriers and their licensed agents may contact the Board's Bureau of Compliance to obtain

this form.

DB-155 Compliance With Disability Benefits

Law

Employers with Board-approved self-

insurance for disability benefits

Filed with the government agency issuing a permit, license or contract. The

DB-155 must be completed by the Board's Self-Insurance Office.

Upon obtaining a permit, license or contract from a government agency. Board-approved self-insured employers must obtain this form from Board's Self-

Insurance Office. (518-402-0247)

WC/DB Exemptions

Form Number Form Title Who Files

CE-200 Used as a paper application for Form CE-200

which replaces Forms WC/DB-

100 and C-105.21.

Paper application for the CE-200,

Certificate of Attestation of

Exemption from NYS Workers' Compensation

and/or Disability Benefits Coverage

A paper application to obtain the CE-200. The CE-200 is used by the applicant to certify they

are not required to carry workers' compensation and/or disability benefits when obtaining a

license, permit, or contract from State, county or municipal agencies in New York State.

Applicants using this paper application process may wait up to four weeks before receiving a

CE-200. This delay results from Workers' Compensation Board staff having to manually enter information from the applicant's paper application into the web based application.

Accordingly, to avoid delays, all applicants for exemptions are strongly encouraged to use the

on-line Form CE-200.

CE-200 online

(Replaces WC/DB-100 and Form C-105.21)

Certificate of Attestation of

Exemption from NYS Workers' Compensation

and/or Disability Benefits Coverage

Applicants for permits, licenses or contracts from State, county or municipal agencies in New

York State that are not required to carry NYS workers' compensation and/or disability benefits

insurance coverage.

Where to File Mail the completed CE-200 APPLY application to:

NYS WCB Bureau of Compliance

Form CE-200 100 Broadway

Albany, NY 12241-0005 or

Fax: 800-486-7175 Once the applicant receives the CE-200, the applicant can then verify the information on the CE-200, sign it and then submit that

CE-200 to the government agency from which he/she is getting the permit, license or contract.

Please also print the related instructions for filling out Form CE-200 Help Line: Business Express: 518-485-5000 option #4

Worker's Compensation phone: 877-632-4996Please file with the government agency that is issuing the permit, license or contract. (Examples: The New York City Department of

Buildings or the New York State Department of Health) These exemption forms can ONLY be used to attest to a

government entity that an applicant requesting a permit, license or contract from that government entity is not required to carry NYS

workers' compensation and/or disability benefits insurance. Apply on line: www.businessexpress.ny.gov

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Clinton County Health Departnient133 Margaret Street, Plattsburgh, New York 12901-2926

"Working Together for a Healthier Community"

www. cUntonhealth. org

^

PuMteHeaMfaPrevent. Promote. Prottct.

Environmental Health & Safety Division Phone: (518)565-4870

SPECIAL

New York State Worker's Corn ensation DisabilitInsurance Re uirements

Fax: (518)565-4843

Benefits

Effective December 1, 2008 the New York State Worker's Compensation Board (WCB) hasreplaced Form WC/DB-100 (previously used to demonstrate exemption from WC/DBinsurance requirements) with the new Certificate of Exemption (Form CE-200).Consequently, every permittee MUST EITHER:

A) Provide current insurance policy information (see application section G)

OR

B) File a current Certificate of Exemption (CE-200) form with your Department ofHealth permit application.

Failure to provide complete and accurate information about Worker'sCompensation/Disability Insurance, or proof of exemption, will preclude the HealthDepartment from issuance/renewal of you permit. Current forms must be attached toour a lication each ear or the ermit will be denied in accordance with the New

York State Worker*s Corn ensation Law NYSWCL .

An overview that clarifies the requirements and the CE-200 exemption form can be foundon the WCB website:(www.wcb.n . ov content ebiz we db exem tions re uestexem tionoverview. 's . Newinstructions for obtaining a certificate of exemption through the NY Business Expresswebsite are printed on the reverse side of this notice.

If ou have uestions or need assistance ou must call 1-877-632-4996.

The majority of these forms will be processed electronically. Applicants with internet accessmust complete the questionnaire online and print a copy of the CE-200 exemption toenclose with your permit application. Applicants without internet access should call thehelp line number above to request a paper form for mailing. However, be advised that mailapplicants may wait up to four weeks before receiving their approved CE-200 form. Toavoid dela s ALL a licants are stron 1 encoura cd to use the online form.Therefore if ou do not have a corn uter with internet access we su est ou visit ourlocal libra to use one.

.-^

"Persons who have any physical mobility or other needs, call the telephone number above to arrange for accommodations"

Snstructlons fw obtaining and ffliog a Certificate of Exemptlorvro-m 'Workers^ Compensatloii and/or Dlsablliity arsd Paid FamiiyLeave Ben^ts .(CE-2.00) throug:h New^brk Busj:nQss Express

1. Gor:to tei.isiniessexpress. fty. gov.

2, Select Log-!nfl?eg. lster in the top nghthand corner,

3. If you do net have an NYgpv account,go to step 4 to set. up your aeeount..

If you, have an NY.gov to.g-in -and: password,.go to step 16.

4. Select, Register vrith NY.gov yneler New l.Jsers.

5. Sele.ct PrQceed,

6. Enter the fol.lowing;-First and LastNa me

^. Email

1'Confirm Email

:. Preferted Usernarne (check jf usefname is avaflable).

"I, Select fin not a tobcrt.

.. Vbu may Mave fQ comjSilete a Captcftg VerificationBefore p.roeeeding.

8. Select Cre&te Account,

r. If you already have an .NY;g6v aceoynt, the screenwill display your existing accounts, .either Individual<3r Business.

Qo on^ of the following:

(f the accounts) shown is an NYgovlncfivjdualacGourtt, select Continue.

lfthe-accaunt(s) shQwn 'Is an NY.gov Businessaccount, select Email Me the Username(s).

9., Verify that fee accQunt information is correct.. Sdect Continue.

10. An aclivaflon email, will. be sent.

If you do not receive an emajl,.seeth.e No EmailReceived During AGCdunt Cr@ati9n page,

It Open your activgtion email and select Click Here.

. Specify three security questions.

12, Select Continue.

13, Create a password (must contain gt least eightcharacters).

14. Select Set Password.

. You have successfully activated yQur NY. gov. lD.

IS- Select Go to MyNy,. At the top of the screen select Services.

. Select Business.

i Select New York Business Express.

" Setect Login/Registet.

'i6., Qn tine New York Business Expi'ess HQme Pag6:ScrQJI down to Top Requests and, selectCertificate of Attestation, oj^

Seiarch index A-Z for CE-200.

17. Seiect How to Apply:Select Apply as a Business, w

Select Ap]3ly as a Homeoytfner :(apRljes to thoseQbtaining permits to w6:rk on tbeir residence).

IS. Complete application screens,

1S-. Review Applicati:Qn Sum. mary.

20. Attest and Submit.

You will receive an email when your application has been Issued/Approved.

To view your certificate:r CtfcR Access Recent Activity from yaur email, sr

Access busts6ssexpress. ny.gov, and then accessyour Dashboard (under yoLir Log-ln name on right).

Print and signthe ExemptionCertificate.

Submit your CE-200for your license,permit or contract tothe issuing Agency.

GUIDE TO OBTAINING A PERMIT TO OPERATE A FOOD SERVICE … · 2020-01-22 · GUIDE TO OBTAINING A...

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