Are you a new owner of an existing fixed food premise? Yes No BUSINESS INFORMATION Business Name * Legal Name (if different from above) Proposed Date of Opening Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202420252026 Category of Food Business (select one) * Fixed Food Premises Mobile Food Premises Home-based Food Premises Primary Type of Food Business (select one) * Restaurant Snack bar / refreshment stand Food take out Food caterer Institutional Food Service (hospital, seniors residence, long term care) Banquet facility Shared / community or rental kitchen Child care Cocktail bar Supermarket Convenience / Variety store Warehouse / Distribution Online retail Food processor Special event vendor Farmers market vendor Food truck Ice cream truck Catering truck Food cart Other Other (please specify) Proposed Site Address * Site Name* (if applicable) *Provide name of the community kitchen or commercial kitchen (e.g., church kitchen) if you are planning production there. Fax Number Phone Number * City/Town * Postal Code * Tobacco / Vape Sales * Yes No Website Proposed Number of Seats (if applicable) Proposed Number of Employees Year-round or Seasonal * Year-round Seasonal If seasonal, months of operation Water Supply * Municipal Private Sewage Supply * Municipal Private Pest Control Contracted * Yes No Liquor License * Yes No MAILING ADDRESS (if different than site address above) Mailing Address City/Town Postal Code Fax Number OWNER INFORMATION Owner Name * Phone Number * Owner Email Address * Confirm Owner Email Address * PRIMARY CONTACT INFORMATION (if different from Owner) Primary Contact Name Primary Contact Phone Primary Contact Email Address Confirm Primary Contact Email Address CORPORATE INFORMATION (if applicable) Corporation Name / Number Corporation Phone Number Corporation Address Corporation City Corporation Postal Code Name of Principal Officer PLEASE ACKNOWLEDGE THE FOLLOWING: I understand that unless specifically advised to the contrary, I will be required to ensure that there is at least one food handler or supervisor on the premise who has an up-to-date Food Handler Certificate during every hour in which the premise is operating. * Yes O. Reg 493/17: FOOD PREMISES I understand all equipment, including cooking equipment, temperature-controlled compartments and sanitation facilities will need to be fully functional at the time of the pre-opening inspection in order to receive approval to open. * Yes I understand that I will be required to submit floor plans / drawings electronically for review by public health prior to opening and ideally prior to construction activities commencing. * Yes The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of healthcare databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 2975.
