2018 Establishment name: Physical address: City: ZIP: Phone: Fax: Email: Owner/Operator: Mailing address: City: State: ZIP: Phone: E-mail: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Open Close - 3) Name CFPM Number Expiration Date _____Category 1 High Risk - $200 – _____Category 2 Medium Risk - $175 – _____Category 3 Low Risk - $150 – ** No fee required for not-for-profit organizations _____Seasonal Service (up to 184 days per year) - $100 By signing this form, you attest to the accuracy of the information provided and that you will comply with the Illinois Food Service Sanitation Code. Signature:_____________________________________________ Date:______________________________ Date received:_______________ Amount:____________ Permit number:______________________ Check number:___________________ Initials:________ Date issued:______________________
2018 Establishment name: Physical address: City: ZIP: Phone: Fax: Email: Owner/Operator: Mailing address: City: State: ZIP: Phone: E-mail: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Open Close - 3) Name CFPM Number Expiration Date _____Category 1 – High Risk - $200 _____Category 2 – Medium Risk - $175 _____Category 3 – Low Risk - $150 _____Seasonal Service (up to 184 days per year) - $100 ** No fee required for not-for-profit organizations By signing this form, you attest to the accuracy of the information provided and that you will comply with the Illinois Food Service Sanitation Code. Signature:_____________________________________________ Date:______________________________ Date received:_______________ Amount:____________ Check number:___________________ Initials:________ Permit number:______________________ Date issued:______________________
2018_Permit_Application.docx