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2. The intent of this application is to provide information regarding the operational procedures of the facility.
4. Construction Type

   1. New
   2. Remodel Existing Structure
   3. Change of Ownership
6. Establishment Plans
   Upload Establishment Plans
10. Name of Facility
12. Facility Phone Number
14. Physical Address of Facility
16. City
18. Zip Code
22. Owner of Facility
24. Owner Phone Number
28. Mailing Address of Facility
30. City
32. State
34. Zip Code
38. Applicant / Contact Person
40. Phone Number
42. Relation to Owner

    1. Architect
    2. Owner
    3. Employee
    4. Contractor
    5. Other
44. If other, please specify.
48. Scope of Work
50. Year Structure Was Originally Built
52. Original Owner
54. Sewage Disposal

    1. Municipal
    2. Septic Tank
    3. Other
56. Water Supply

    1. Municipal
    2. Well
    3. Other
58. Meals Provided

    1. Breakfast
    2. Lunch
    3. Dinner
    4. Students/Patrons will bring bag lunch
60. Meal Preparation

    1. On-Site
    2. Off-Site
62. Please specify the location where meals are prepared and how they are transported.
64. Dining Utensil Type

    1. Single-Service
    2. Multi-Use
66. Proposed Operating Days & Hours
68. Proposed Date That Facility Will Open
    Proposed Date That Facility Will Open
70. Number of Children/Residents/Patrons Presently or Requesting Licensing For
72. School Grades

    Check all that apply.

    1. Pre-K (Partial Day)
    2. K
    3. 1
    4. 2
    5. 3

    1. 4
    2. 5
    3. 6
    4. 7
    5. 8

    1. 9
    2. 10
    3. 11
    4. 12
76. Acknowledgement*

    I certify that the information in this application is correct, and I understand that any deviation without prior approval from this Health Regulatory Office may nullify plan approval.

    1. I understand.
78. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
80. Electronic Signature*
82. Date*
    Date
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field