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San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
sanjuanpublichealth.org
Application For Food Service Establishment Permit
(Seasonal or Annual)
*Please note that a permit will not be issued until this form is submitted and payment has been received.
Establishment Information
Who is (are) the current certified manager(s)?
Food Safety Manager Certification Expiration Date(s):
UPLOAD CURRENT FOOD SAFETY MANAGER CERTIFICATE HERE
Establishment Name
Establishment Street Address:
City
Phone Number:
Hours of Operation:
Is the establishment seasonal?
Yes
No
IF SEASONAL please indicate MONTH OPEN:
January
February
March
April
May
June
July
August
September
October
November
December
IF SEASONAL please indicate MONTH CLOSED
January
February
March
April
May
June
July
August
September
October
November
December
Owner's Information
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
The San Juan Public Health Department has adopted by reference the current State of Utah, Department of Health, Food Service Sanitation Rule R392-100
Each food establishment must have a person with an approved Food Safety Manager Certificate (R392-101).
Food Safety Manager Certification is valid for ONLY 3 years in the State of Utah. Please attach a current certificate to this application with the link provided.
Unless already a Certified Food Manager, all employees must have a current Food Handlers Card.
The Food Service Sanitation Rule requires all food establishments to be inspected by the Health Department.
A proper handwashing station must be set up and operational prior to and during any food preparation or food handling.
Noncompliance with the food code or any of the stipulations listed above may result in the immediate suspension of the seasonal food establishment permit.
If your establishment is annual OR open MORE THAN 5 MONTHS please select the checkbox below for the annual permit. Otherwise, choose the seasonal permit.
Seasonal Food Permit (5 Months):
$50.00
Select:
Item Subtotal:
$0.00
Annual Food Service Permit (12 Months):
$100.00
Select:
Item Subtotal:
$0.00
Total:
$0.00
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($1.50 min)
(1.5% additional service fee for foreign cards)
eCheck:
$0.75
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Payment method will be collected on external device
Change Payment Method
I Agree
Statement: I hereby certify I have read and agree to comply with all statements on this form, and that all information provided is correct. I fully understand that any deviation without approval from the San Juan County Health Department may be grounds for suspension of any permit issued. The health department can make additional requirements.
Applicant's Signature
Date
Submitting ...
Cancel
Who is (are) the current certified manager(s)?
is required
Food Safety Manager Certification Expiration Date(s):
is required
Establishment Name
is required
Establishment Street Address:
is required
City
is required
Phone Number:
is required
Hours of Operation:
is required
First Name: is required
Last Name: is required
Address: is required
City: is required
State/Province: is required
ZIP/Postal Code: is required
Phone: is required
Email: is required
'
I Agree
' must be checked to submit
Applicant's Signature
is required
Date
is required
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