San Juan County Public Health
             
San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838

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):
Establishment Name
Establishment Street Address:
City
Phone Number:
Hours of Operation:
Is the establishment seasonal?
Yes
No
IF SEASONAL please indicate MONTH OPEN:
IF SEASONAL please indicate MONTH CLOSED
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% surcharge 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:
 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
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