San Juan County Health Department
735 S 200 W STE 2, Blanding, UT, 84511
Phone (435) 587-3838
Application For Initial (Start-up) Food Service Permit
*Please note that a permit will not be issued until this form is submitted and payment has been received.
Who is (are) the current certified manager(s)?
Food Safety Manager Certification Expiration Date(s):
UPLOAD CURRENT FOOD SAFETY MANAGER CERTIFICATE HERE
Establishment Street Address:
Hours of Operation:
Is the establishment seasonal?
IF SEASONAL please indicate MONTH OPEN:
IF SEASONAL please indicate MONTH CLOSED
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.
Initial Food Service Permit (Valid for 12 Months):
Processing Fee Rates:
2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
Method of Payment:
Update Name from Personal/Organizational Information
Name on Account:
Name on Card:
Billing Street Address:
Billing ZIP/Postal Code:
Change Payment Method
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.
CORE Business Technologies
DBA Secure Instant Payments. All rights reserved.
SIP Version 3.22.16528; (API: 2.22)