Application for Food Premises Licence - North 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.

* 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:
* 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 - ($50)
Class 4 - ($265)
Class 5 - ($350)
Class 5 - Abattoir ($475)
Class 5 - Dairy Plant ($1,050)
Class 5 - Maple Syrup ($50)
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)


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