1. 1. The name, mailing address, telephone number, and signature of the person applying for the permit and the name, mailing address, and location of the food establishment;
2. 2. Information specifying whether the food establishment is owned by an association, corporation, individual, partnership, or other legal entity;

3. 3. A statement specifying whether the food establishment:

   1. a. Is mobile or stationary, and temporary or permanent; and

   2. b. Is an operation that includes one or more of the following:

      1. (1) Prepares, offers for sale, or serves time/temperature control for safety food:

         1. (a) Only to order upon a consumer's request;
         2. (b) In advance in quantities based on projected consumer demand and discards food that is not sold or served at an approved frequency; or
         3. (c) Using time as the public health control as specified under 12VAC5-421-850;
      2. (2) Prepares time/temperature control for safety food in advance using a food preparation method that involves two or more steps which may include combining time/temperature control for safety food ingredients; cooking; cooling; reheating; hot or cold holding; freezing; or thawing;
      3. (3) Prepares food as specified under subdivision 3 b (2) of this section for delivery to and consumption at a location off the premises of the food establishment where it is prepared;
      4. (4) Prepares food as specified under subdivision 3 b (2) of this section for service to a highly susceptible population;
      5. (5) Prepares only food that is not time/temperature control for safety food; or
      6. (6) Does not prepare, but offers for sale only prepackaged food that is not time/temperature control for safety food;
4. 4. The name, title, address, and telephone number of the person directly responsible for the food establishment;
5. 5. The name, title, address, and telephone number of the person who functions as the immediate supervisor of the person specified under subdivision 4 of this section such as the zone, district, or regional supervisor;

6. 6. The names, titles, and addresses of:

   1. a. The persons comprising the legal ownership as specified under subdivision 2 of this section including the owners and officers; and
   2. b. The local resident agent if one is required based on the type of legal ownership;

7. 7. A statement signed by the applicant that:

   1. a. Attests to the accuracy of the information provided in the application; and

   2. b. Affirms that the applicant will:

      1. (1) Comply with this chapter; and
      2. (2) Allow the department access to the establishment as specified under 12VAC5-421-3820 and to the records specified under 12VAC5-421-440 and 12VAC5-421-2330 and subdivision 4 of 12VAC5-421-3630; and
8. 8. Other information required by the department.

The application shall include:

Statutory Authority

§§ 35.1-11 and 35.1-14 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 18, Issue 10, eff. March 1, 2002; amended, Virginia Register Volume 24, Issue 2, eff. October 16, 2007; Volume 32, Issue 22, eff. July 12, 2016; Volume 37, Issue 18, eff. June 10, 2021.