Food Store License Online 2021-2026

FSI 302 1/17 APPLICATION FOR RETAIL FOOD STORE LICENSE ARTICLE 28-A NYS Department of Agriculture and Markets Attn Food Safety License Unit 10B Airline Drive Albany New York 12235 Office Use Only LICENSE FEE 250. Please complete the information below credit card account indicated below for 250. 00. This payment is for a RETAIL FOOD STORE LICENSE Billing Address Phone City State Zip Email Account Type Visa MasterCard AMEX Discover Cardholder Name Account Number Expiration Date CVV2 3 digit number on back of Visa/MC 4 digits on front of AMEX SIGNATURE FOR OFFICE USE ONLY Estab No. License No. I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for a Retail Food Store License for the amount indicated above only and is valid for one time use only. 00 County Code- Est. No* License Expiration Two years from date of issuance. Entity No* Receipt No* Verification No* INSTRUCTIONS Read and complete both sides of this application* Prepare a separate application for each location* An original signature of owner or corporate officer is required in Section 7. NOTE This license is ONLY for retail food stores that do not conduct any type of food processing operations e*g* prepare sandwiches cook food on premises. If you conduct food processing operations you must file a Food Processing Application* Inspections are scheduled after applications are received and reviewed* 1 Individual Owner Name Partnership or Full Name of the Corporation County Trade Name Business Telephone Number Street City E-Mail Bank Name State Zip 2 Optional Mailing Address 3 Identification Number Federal ID Number OR Social Security Number 4 Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership LLC or LLP list partners/members attach list if necessary. If applicant is a non-public corporation list shareholders attach list if necessary. Name Please Print Title Contact Address Street No* City State Zip E-Mail address Date of Birth 4a* Principal Office Address 4b. In what state incorporated 4c* Date of Incorporation 4d. Are you a foreign or out-of-New-York-state individual partnership or corporation Check One Yes No 4e. For foreign or out-of-New-York-state corporations Date of filing in New York State 4f* If out-of-New-York-state the applicant agrees to accept service of process by first class mail to the designated individual at the said address below which shall constitute good and proper service of process. Designated Address PLEASE COMPLETE REVERSE SIDE 5 You are REQUIRED to be licensed if you offer for sale potentially hazardous food which can include any of the following milk shell eggs refrigerated meats and dairy products. List all of the foods to be covered by this license at the location listed on the front of this application* 6 Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate Workers Compensation Insurance WCI.