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Food Service Permit Application

2. Food Service Permit Application
3. 
5. Name of Business:
6. APP.#
8. Address:
9. Phone Number:
11. Type:
12. Date:
14. Name of Owner(s):
16. Home Address:
17. Home Phone:
19. Check one:

    1. Individual

    1. Corporation

    1. Partnership
21. Name & Title:
22. Address:
23. Phone:
25. Name & Title:
26. Address:
27. Phone:
29. References:
31. Name:
32. Address:
33. Phone:
35. Name:
36. Address:
37. Phone:
39. Prior Experience:
41. Certified Food Manager's Name & Certificate Number:
43. Building Owner & Address:
45. No. of Employees:
47. Copy of Village of Skokie Food Service Ordinance Received?

    1. Yes

    1. No
49. Permits shall not be transferable from one person to another person or place. A valid permit shall be posted in every food service establishment.
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature*
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field