Food Establishment Permit Application

PLEASE NOTE: Filling out this application does NOT guarantee you permission to operate. You MUST contact the Platte County Health Department in order to complete the application process. Return completed application at least 10 business days prior to planned opening date.

Date*

Date

Application Type*

New EstablishmentExtensive Remodeling

Applicant must be owner or an officer of the legal ownership of the food establishment.

Applicant Name*

First NameLast Name

Food Establishment Legal Name*

Owner Name*

First NameLast Name

Establishment Phone*

After Hours Emergency Phone Number*

Please enter a valid phone number.

Food Establishment Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address for Permitting*

example@example.com

Email Address for Billing*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Site Contact Name*

First NameLast Name

Email For Inspection Reports*

example@example.com

Days of Operation*

Hours of Operation a.m./p.m. to a.m./p.m.*

Projected Number of Certified Food Handlers*

Water Source*

PublicPrivate

Will the food establishment sell/serve potentially hazardous foods (PHF)/time temperature control for safety foods (TCS) that are commercially pre-packaged in an approved processing facility?*

YesNo

Will the food establishment sell/serve non PHF/TCS that are not pre-packaged (pastries, snack foods, etc.)?*

YesNo

Will the food establishment sell/serve non-pre-packaged beverages (alcoholic or non-alcoholic)?*

YesNo

Will the food establishment reheat commercially processed PHF/TCS (hotdogs, smoked sausages, taquitos, etc.)*

YesNo

Will the food establishment prepare foods from raw ingredients?*

YesNo

Will the food establishment be cooking PHF/TCS that is served immediately?*

YesNo

Will the food establishment be cooling or reheating three (3) or less different PHF/TCS food items?*

YesNo

Will the food establishment hold PHF/TCS in hot or cold holding units after preparation or cooking?*

YesNo

Will the food establishment be cooling and reheating four (4) or more different PHF/TCS food items?*

YesNo

Will the food establishment prepare hot or cold PHF/TCS and hold those foods hot or cold for more than twelve (12) hours before serving?*

YesNo

Will the food establishment prepare PHF/TCS foods in advance for next-day service?*

YesNo

Will the food establishment be serving raw or undercooked PHF/TCS?*

YesNo

Will the food establishment be using and specialized process including vacuum packaging and/or other forms of reduced oxygen packaging, smoking or curing to extend shelf-life?*

YesNo

Will the majority of the people served by the food establishment be highly susceptible individuals, such as the elderly, people with a compromised immune system or children under the age of 4?*

YesNo

Schematic drawing of floor plan of kitchen and dining areas showing the layout of stoves, refrigeration, freezers, worktables, hand sinks, prep sinks, dry storage, beverage stations, etc.*

Employee illness policy - illness policy must comply with minimum requirements of sections 2-201.12 to 2-201.13 of the Missouri Food Code.*

A properly completed application shall be submitted.
The application and accompanying documents shall be reviewed and approved.
A pre-opening inspection of the establishment with equipment in place will be conducted to determine if the facility complies with the provisions of the code.
Only establishments that have completed the above items shall be approved to operate as food establishments.
The owner(s) agree to:
- Comply with the Missouri Food Code and Platte County Food Ordinance.
- Allow the regulatory authority access to the food establishment.
- Provide records specified by the Missouri Food Code and Platte County Food Ordinance.

I certify that the information supplied in this application is complete and true to the best of my knowledge and I understand that any misstatement or omission of fact will render this application and any permit issued invalid.

I am familiar with the contends of the Missouri Food Code and the Platte County Food Ordinance and understand that my food service permit may be suspended or revoked by the Platte County Health Department for failure to comply with the provisions of the Platte County Food Code.

If approved, I understand that food establishment permits may not be transferred from one person to another, from one location to another or from one type of operation to another type of operation.

Signature of Owner*

Clear

Plan Review Fee

$50.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Food Establishment Permit Application

Establishment Information

Risk Assessment

Required Attachments

Read Before Signing