2. Applicant First Name
3. Applicant Last Name
5. DBA/Business Name
7. Address of Business
9. City
10. State
11. Zip Code
13. Business Mailing Address
15. City
16. State
17. Zip Code
19. Phone Number
20. Fax Number
22. Email Address
24. Hours of Operation
25. Will there be alcohol on the premises?

    1. Yes
    2. No
26. If Yes, License #
28. Description of licensed premises:
30. # of Seats/Occupancy:
32. Briefly describe proposed cooking facilities:
34. Briefly describe facilities for cleaning of cooking and eating utensils:
36. Briefly describe facilities for food refrigeration:
38. Briefly describe facilities for food storage:
40. Electronic Signature*
    *Typing your FULL NAME represents your official signature
41. Date
    Date

    Date
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field