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 email a current certificate to publichealth@sanjuancountyut.gov.
  • 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 food establishment permit.

Tier 1: 
Establishments that serve or sell only pre-packaged, non-potentially hazardous foods. Establishments that heat only commercially processed potentially hazardous foods for hot holding. Examples include convenience store operations, coffee shops, soda shops, etc.

Tier 2:
Establishments with a limited menu where most products are prepared/cooked and served immediately. Examples include retail food store operations, quick service operations, bakeries, grocery store deli, etc.

Tier 3: 
Establishments with an extensive menu and handling of raw ingredients. Complex preparation including cooking, cooling, and reheating for hot holding and involves many potentially hazardous foods. Examples include full service restaurants.

Tier 4: 
Establishments serving a highly susceptible population or that conducts specialized processes. Examples include schools, hospitals, nursing homes, etc.


Please reference tier levels above when selecting your permit.
For establishments operating for 6 months or less, select the "Seasonal Food Permit" option regardless of tier.
Seasonal Food Permit (6 Months):   $55.00   Select:   Item Subtotal:  
$0.00
Annual Tier 1:   $109.00   Select:   Item Subtotal:  
$0.00
Annual Tier 2:   $131.00   Select:   Item Subtotal:  
$0.00
Annual Tier 3:   $164.00   Select:   Item Subtotal:  
$0.00
Annual Tier 4:   $219.00   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 ...