The Fsapp 01 01 11 form is an application for an annual food service license issued by the New Hampshire Department of Health and Human Services. This form requires essential information about the food establishment, including ownership details, location, and operational specifics. Completing this form accurately is crucial for compliance and the successful operation of your food service business.
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The Fsapp 01 01 11 form is an essential document for food service establishments in New Hampshire seeking an annual food service license. This application is managed by the New Hampshire Department of Health and Human Services, specifically through the Food Protection Section. The form requires detailed information about the establishment, including the legal name of the owner or corporation, the name and location of the establishment, and contact details. Applicants must also specify their type of ownership and the class of license they are applying for, which can vary based on seating capacity and food preparation areas. Additional requirements include submitting supporting documentation, such as laboratory analysis of water quality and floor plans for new establishments. Incomplete applications will be returned, emphasizing the importance of thoroughness. The form also provides space for the applicant's certification, ensuring that all information is accurate and up-to-date. Understanding the requirements and properly completing the Fsapp 01 01 11 form is crucial for compliance and successful operation in the food service industry.
STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF PUBLIC HEALTH SERVICES
FOOD PROTECTION SECTION
29 HAZEN DRIVE, CONCORD, NH 03301-6503
603-271-4589
FAX: 603-271-4859 TDD Access: 1-800-735-2964
Website: www.dhhs.nh.gov
E-mail: foodprotection@dhhs.state.nh.us
APPLICATION FOR ANNUAL FOOD SERVICE LICENSE
1Full Legal Name of Corporation, LLC or Owner(s)
2Name of Establishment
3Location (Street)
(Town, State)
(Zip)
4Mailing Address (if different)
5Telephone # of Establishment (
)
6Emergency Contact Telephone # (
7Fax # (
8Email Address
9Name of Person in Charge at Establishment
10Schedule of Operation
11Previous Business Name of Establishment
12Renting/Space Sharing with another licensee?____No____Yes(enter name)
13Type of Ownership
14Type of License
15Current Establishment #
Sole Proprietorship
Corporation
New Establishment
16Current License #
Joint Venture
Limited Liability
Change in License Class
17Town Water
Yes or
No
Partnership
Other (Specify)
Change of Ownership
17Town Wastewater Yes
or No
Renewal
18Number of Seats (indoor)
19Public Water System/(EPA)
20Class of License - check highest class and class category
Class A ($875)
food establishment (FE) with 200 seats or more (2) retail food store with 4 or more prep areas (3)
Class B ($450)
retail food store with 2-3 food prep areas (1) FE with 100-199 seats (2)
Class C ($350)
retail food store with one food prep area (1) caterers off-site (2)
FE with 25-99 seats (3) bar/lounges with food prep area (4)
Class D ($225)
FE with 0-24 seats (including but not limited to bakeries) (1) fraternities and sororities (2)
retail food store – self services (4) servicing areas (6)
Class E ($175)
bed and breakfast (1)
ice cream vendors - scooping (2)
lodging facilities serving continental breakfast (3)
Class F ($150)
retail food store - no food prep area (3) wholesalers/distributors TCS food (4)
on-site vending machines - serving TCS food (5) bakeries which do not serve TCS food / 0 seats (6)
Class G ($100)
bar/lounges with no food prep area that serve alcohol (1) arena/theater concessions serving non-TCS food (2) retail food stores serving pre-packaged ice cream only (3) institutions including state, county and municipal institutions (4) private schools (5)
senior meal sites (6)
sellers of prepackaged frozen USDA meat or poultry (7)
Class O (No Charge)
municipality operated school cafeterias.
DEFINITIONS
FE-Food Establishment
TCS-Time/Temperature Control for food safety
* *Submit all Supporting documentation. Incomplete applications will be returned.
21
All applications-Written results of laboratory analysis of water for bacteria, nitrates and nitrites. (n/a if Town Water)
New applications only: Floor Plan –Include additional $75.00 review fee. See Application Form PRAPP 01-01-11.
New/Change of Ownership: applications-Septic Approvals for Construction AND Approvals for Operation.(n/a if Town Wastewater)
I, (print name & title)22,23______________________________________________________, certify that all information provided in or
attached to this application is complete, accurate and up-to-date as of the date specified below. I further certify that there are no willful misrepresentations of the answers to questions herein, and that I have made no omissions with respect to any of my answers to the questions presented. I understand that it is my responsibility to immediately notify the Food Protection Section with regard to any changes, corrections or updates to the information provided.
SIGNATURE OF APPLICANT: 24___________________________________________________DATE OF APPLICATION: 25________________
-----------------------------------------------DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY---------------------------------------------------
Date Received___________Check #_______________________Check Amount___________Plan Review Plan Review Check #_______________
Provisional Date_______________S_________R_________Final Date_______________S__________ AUDIT#_________________________________
NH Department of Health & Human Services, Food Protection Section
T:\OCPH\EPI\FPS\Group\2011 Food Rules\Applications\2010 Food Service License
Application 12-10.doc
Form FSAPP 01-01-11
INSTRUCTIONS FOR COMPLETING
APPLICATION FOR FOOD SERVICE LICENSE
Please fill in all blanks, if not applicable enter “NA”, except steps 14 and 15 (leave blank if not known).
1.Full Legal Name of Corporation or Owner - provide the full legal name of the corporation or owner(s) of the establishment.
2.Name of Establishment - provide the full name of the establishment.
3.Location - provide location of establishment to include street number, street name, city/town, state, and zip code.
4.Mailing Address - provide mailing address if different than establishment location.
5.Telephone # of Establishment - provide the on-site telephone number for the establishment.
6.Emergency Contact Telephone Number - provide telephone number for individual who should be contacted in an emergency.
7.Business Fax Number - for faxing information.
8.Email Address - provide Email address if available.
9.Name of Person in Charge at Establishment - provide the name of the individual who is in charge at the establishment.
10.Schedule of Operation-provide hours,days, and weeks per year this establishment will operate.
11.Previous Business Name of Location - provide the previous name of establishment.
12.Renting/Space Sharing-if yes, indicate name and location of other licensee.
13.Type of Ownership - check the appropriate ownership type of the establishment, if other please specify.
14.Type of License - check the appropriate license type that you are applying for.
15.Current Establishment # - provide current establishment number if known, otherwise please leave blank.
16.Current License # - provide current license number if known, otherwise please leave blank.
17.Town Water/Town Wastewater - circle “Yes” if establishment has town water or wastewater, “No” if it does not. If “No” refer to water and wastewater requirements document.
18.Seating Count – provide total number of indoor seats for the establishment.
19.Public Water System/(EPA) Number – water results sampling number, if applicable.
20.Class of License - check highest class and class category. Example; Class A FE w/200 seats or more.
21.Requirements - check each item applicable and submit supporting documentation.
22.Printed Name - print full name of establishment’s legal owner signing application or officer of legal owner who applies for the license.
23.Title - provide title of establishment’s applicant.
24.Signature - provide original signature of establishment’s applicant.
25.Date - provide current date.
Please note, there are sixteen Self-Inspecting Cities/Towns in the state of NH, in which case you will need to contact directly for licensing if the food establishment is located in those areas. They are: Bedford, Berlin, Claremont, Concord, Derry, Dover, Epsom, Exeter, Keene, Manchester, Merrimack, Nashua, Plaistow, Portsmouth, Rochester and Salem. For contact information, please refer to www.dhhs.state.nh.us.
SUBMITTING YOUR APPLICATION
1.Payment, payable to “Treasurer, State of New Hampshire,” must accompany application. Payments are non- refundable and non-transferable.
2.Incomplete or illegible applications or applications not accompanied by payment, water test results, product list, or any other applicable attachments, will be returned. Completed application(s) should be forwarded to the Food Protection Section, 29 Hazen Drive, Concord, NH 03301.
3.For “Change in License Class, New or Change of Ownership” applications. Thirty (30) days after forwarding this application with all the required applicable paperwork to the Food Protection Section, call (603) 271-4589 to leave a message for your inspector to arrange for an inspection of your facility. (Please allow seven (7) business days notice for inspection appointment)
For additional information or for further assistance, please contact the NH Department of Health and Human Services, Division of Public Health Services, Food Protection Section at (603) 271-4589 or foodprotection@dhhs.state.nh.us.
What is the Fsapp 01 01 11 form used for?
The Fsapp 01 01 11 form is an application for an annual food service license in New Hampshire. This license is required for establishments that prepare and serve food to the public. It helps ensure that food safety standards are met, protecting public health.
Who needs to fill out this form?
Any food establishment operating in New Hampshire must fill out this form to obtain a food service license. This includes restaurants, caterers, food trucks, and any other business that serves food. If there is a change in ownership or license class, a new application is also required.
What information is required on the form?
The form requires various details, including the full legal name of the owner or corporation, the establishment's name and location, contact information, type of ownership, and the number of seats available. Additionally, applicants must provide information about water and wastewater systems, as well as the type of license they are applying for.
What happens if the application is incomplete?
If the application is incomplete or illegible, it will be returned. Applicants must ensure that all sections are filled out correctly and that all required supporting documents are included. This includes payment, water test results, and any other necessary attachments.
How much does it cost to apply for a food service license?
The cost of applying for a food service license varies depending on the class of license. For example, a Class A license costs $875, while a Class G license costs $100. The specific fee should be checked on the application form based on the type of establishment.
What should I do after submitting my application?
After submitting the application, you should wait thirty days before calling to schedule an inspection. This is necessary for new applications or changes in ownership or license class. Be sure to provide at least seven business days' notice for the inspection appointment.
Where can I find more information about the application process?
For more information, you can visit the New Hampshire Department of Health and Human Services website or contact the Food Protection Section directly at (603) 271-4589 or via email at foodprotection@dhhs.state.nh.us. They can provide guidance and answer any specific questions you may have.
Understanding the Fsapp 01 01 11 form is crucial for anyone looking to apply for an annual food service license in New Hampshire. However, several misconceptions often arise. Here are six common misunderstandings:
By clearing up these misconceptions, applicants can navigate the licensing process more effectively and ensure compliance with state regulations.
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