SPRINGDALE HEALTH DEPARTMENT
11700 SPRINGFIELD PIKE
SPRINGDALE OH 45246
Application for permit to operate a
Food Establishment as required by Environmental Sanitation Regulation 1-83 for the year 1999-2000.NO PERSON SHALL OPERATE A FOOD ESTABLISHMENT WITHOUT HAVING A PERMIT ISSUED BY THE SPRINGDALE BOARD OF HEALTH.
NAME
OWNER
ADDRESS
CITY STATE ZIP CODE
PHONE NUMBER
Mailing address if different from above:
If above information has changed since last application, indicate previous name of establishment and owner.
I hereby certify that I am the operator of the food establishment named above.
Date: _________________ Signed (x) __________________________________
Send application and remittance to: Springdale Health Department
11700 Springfield Pike
Springdale OH 45246
Date due: Permit Fee: $ .00
THE APPLICANT GRANTS THE RIGHT OF INSPECTION TO SPRINGDALE HEALTH DEPARTMENT REPRESENTATIVES DURING NORMAL WORKING HOURS
………………………………………..DEPARTMENT USE ONLY ……………………………
APPLICATION APPROVED FOR PERMIT AND CERTIFICATION AS REQUIRED BY REGULATIONS #423 AND #507 OF THE SPRINGDALE BOARD OF HEALTH.
Date Received ____________________ Approved by _______________________
Health Commissioner
Permit No. __________________
FEE SCHEDULE
0 – 5,000 SQ. FT. $50.00
OVER 5,000 SQ. FT. $100.00