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Application for Permit to Operate

2. 

3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894

   Application for Permit to Operate

   Application for Permit to Operate

5. Instructions

   Complete all items that apply to your establishment, sign the application and submit at least 21 days prior to the expected opening date/permit expiration date. A late fee of $50 will be added to total fee if not received in appropriate time

   Complete all items that apply to your establishment, sign the application and submit at least 21 days prior to the expected opening date/permit expiration date. A late fee of $50 will be added to total fee if not received in appropriate time

7. Facility Name*

9. Facility Address*

11. City*

12. State*

13. Zip*

15. Township of:*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield

16. Facility Status*

    1. Profit
    2. Non-Profit

18. Days of Operation*

    1. Sunday
    2. Monday

    1. Tuesday
    2. Wednesday

    1. Thursday
    2. Friday

    1. Saturday

20. Expected Opening Date
    Expected Opening Date

21. Expected Closing Date
    Expected Closing Date

22. Opening Time
    Opening Time

23. Closing Time
    Closing Time

25. Water Supply*

    1. Public (Municipal)
    2. Private (Onsite)

26. Sewage System*

    1. Public (Municipal)
    2. Private (Onsite)

28. Permit Type (Primary Operation)*

    1. Food Service
    2. Temporary Food Service
    3. Mobile Food Service

    1. Temporary Residence
    2. Recreational Campground
    3. Children's Camp

    1. Swimmimg Pool
    2. Bathing Beach

    1. Mobile Home Park
    2. Tattoo / Body Piercing Studio

30. Food Service Type

    1. High Risk Fee: $220
    2. Medium Risk Fee: $110
    3. Low Risk Fee: $85
    4. Catering Only Fee $220
    5. Institutional Food Service Fee $220

    If unsure please contact our office at 786-8894

31. Catering Operation

    1. Yes: Additional Fee: $100
    2. No

33. Temporary Residence Size

    1. 0-30 Units Fee: $85
    2. 30 + Units Fee: $140

35. Temporary Food Service Duration

    1. Temporary Food Stand (One Event) Fee: $55
    2. Temporary Food Stand (More than One Event) Fee: $85

37. Mobile Food Risk

    1. Medium Risk Fee: $110
    2. Low Risk Fee: $85

    If unsure please contact our office at 786-8894

39. Commissary Name and Location

41. Name and Location of Event

43. Foods to be prepared, Supplier of ingredients, Where and How foods will be prepared

45. Operations Associated With Temporary Residence Permit

    1. Foood Service High Risk Additional Fee: $75
    2. Food Service Medium Risk Additional Fee: $50
    3. Food Service Low Risk Additional Fee: $25
    4. Swimming Pool Additional Fee: $75
    5. Bathing Beach Additional Fee: $75
    6. Recreational Aquatic Spray Park Additional Fee: $75

    Choose All that Apply

47. Recreational Campground Number of Sites

    1. 5-75 Sites Fee: $85
    2. 76-200 Sites Fee: $110
    3. More Than 200 Sites Fee: $140

49. Operations Associated With Recreational Campground Permit

    1. Food Service High Risk Additional Fee: $75
    2. Food Service Medium Risk Additional Fee: $50
    3. Food Service Low Risk Additional Fee: $25
    4. Temporary Residence 0-30 Units Additional Fee: $85
    5. Temporary Residence 30+ Units Additional Fee: $140
    6. Swimming Pool Additional Fee: $75 Per Pool
    7. Bathing Beach Additional Fee: $75 Per Beach
    8. Recreational Aquatic Spray Park additional Fee $75 Per Spray Park

51. Children's Camp Type

    1. Day Camp
    2. Overnight Camp
    3. Private For Profit Day Camp Fee: $100
    4. Private For Profit Overnight Camp Fee: $100

53. Operations Associated with Children's Camp Permit

    1. Food Service
    2. Swimming Pool
    3. Bathing Beach

55. Number of Bathing Beaches
    -- Select One --1 Fee: $1652 Fee: $2403 Fee: $3154 Fee: $3905 Fee: $465

57. Number of Swimming / Spa Pools
    -- Select One --1 Fee: $1652 Fee: $2403 Fee: $3154 Fee: $3905 Fee: $465

59. Mobile Home Park Sites

    1. 0-20 Sites Fee: $85
    2. 21-50 Sites Fee: $165
    3. 51-200 Sites Fee: $250
    4. More than 200 Sites Fee: $330

61. Operations For Tattoo / Body Piercing

    1. Tattoo / Body Piercing Shop Permit Fee: $275
    2. Tattoo Artist and or Body Piercing Certification Fee: $150
    3. Tattoo Artist and or Body Piercing Re-Certification Fee: $50

    Shop Permit Covers One Artist at the facility, additional artists must receive their own certification.

65. Legal Operator or Operating Corporation

67. Person In Charge

68. Email Address

70. Address

72. City

73. State

74. Zip Code

76. Phone Number

77. Fax Number

81. Click the appropriate line and submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law:
    
    A. Workers Compensation and Disability Coverage Provided
    
    Workers Compensation

    1. Form C-105.2 - Certificate of Worker's Compensation Insurance
    2. Form U-26.3 - Certificate of Worker's Compensation Insurance
    3. Form SI-12 - Certificate of Worker's Compensation Self-Insurance
    4. GSI-105.2 - Certificate of Participation in Workers' Compensation Group Self-Insurance

82. Upload Workers Compensation and Disability documentation

    Upload copies of the appropriate documentation of compliance with the Worker's Compensation Law

84. And
    Disability Insurance

    1. DB-120.1 - Certificate of Disability Benefits
    2. Form DB-155 - Certificate of Disability Benefits Self-Insurance

86. B. Workers Compensation And Disability Insurance Coverage Not Provided

    1. Form CE-200 - Certificate of Attestation of Exemption from NYS Worker's Compensation and/or Disability Benefits Coverage

90. Payments

    Make check payable to the Wyoming County Health Department:<br>5362 Mungers Mill Road<br>Silver Springs, NY 14550

    Make check payable to the Wyoming County Health Department:
    5362 Mungers Mill Road
    Silver Springs, NY 14550

92. Total Amount Mailed ($)

    Note* Payment may be made online by clicking the link. If payment is not made online the form must be printed and mailed to our office with appropriate fee.

93. Pay Now

    Click here to Pay Online with Gov Pay

    Please pay amount associated with your Permit type and any associated operations included on your permit.

95. E-Signature: False Statements Made on this Application are Punishable Under the Penal Law*

    Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code.

96. 
    Date*
    
    Date

Leave This Blank:


97. 1. Receive email copy
98. Email address

    This field is not part of the form submission.

99. Submit Submit and Print

* indicates a required field