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Application for Food Premises Licence - East Region
Please fill out the information requested below and click on "Add to Basket".
PLEASE NOTE:
Complete the online application form and forward the rest of the information required for your application to your Public Health or Agri-Foods Inspector (refer to the
Application Guide
for contact information).
Your file will not be complete until all of the mandatory attachments (see section 4 of the
Application Guide
) have been submitted to the Health Protection Branch office.
Initial (new) application fees are now prorated (refer to Section 2 of the
Application Guide
for more information).
Prorated fees do not apply to yearly or seasonal food premises renewals.
* Mandatory fields
*
Type of Licence:
New
Renewal
If this is a renewal, indicate licence number:
*
Choose the Health Protection Branch office closest to your location:
Choose
Moncton
Miramichi
*
Name of Food Premises:
*
Name of applicant and any authorized representative:
NBGIC Parcel Identification Number (PID):
*
Mailing Address:
*
Postal Code:
*
Telephone:
Example: (506)555-1234
Fax (if available):
Example: (506)555-1234
Email:
*
Correspondence:
English
French
*
Location of Food Premises:
*
Number of Employees:
*
Type of Establishment:
Class 3
Class 4
Class 5
Class 5 - Abattoir
Class 5 - Dairy Plant
Class 5 - Maple Syrup
Price:
$
$
Seating Capacity:
*
Name of Manager:
*
Water Supply
Communal / Municipal
Private (Drilled Well)
If Private, has a water sample been tested?
Yes
Date
yyyy/mm/dd
No
*
Type of Sewage Disposal:
Communal / Municipal
Private (Septic System)
IMPORTANT - establishments with a private water supply will be required to submit water sample results prior to licensing. Licensed establishments must ensure acceptable (potable) water quality by testing at a frequency established by a Public Health Inspector based on an assessment of the establishment and water supply.
*
Organization or Individual to receive Annual Renewal Notice:
*
Mailing Contact Person:
*
Address to where Renewal Notice is to be mailed:
*
Postal Code:
*
Telephone:
Example: (506)555-1234
Fax (if available):
Example: (506)555-1234
TYPING IN YOUR NAME AND ELECTRONICALLY SENDING THIS FORM CONSTITUTES YOUR ELECTRONIC SIGNATURE.
* Signature of Applicant
* Date(yyyy/mm/dd)