Date:
DOB or SSN
Name:
Facility name:

Mailing address:
City:
State: Zip:

Site address:
City:
State: Zip:
Directions to site:

Home phone number:
Work phone number:

FOOD ESTABLISHMENT INFORMATION

Year of establishment:

Restaurant Caterer School Institution Temporary food stand Tavern Bakery Convenience store: Delicatessen Meat cutting Grocery store Catering

Senior citizen USDA summer feeding Frozen dessert Establishment number:

New facility Existing facility Plans for remodeling

Date attended class:

I certify that the above information on this form is true and correct and I understand that false statements are punishable under Missouri law.

Owner / Representative name:

The person in charge and designated person(s) in charge must attend food handler's training annually.

FEES

Training fees	A charge may be made for the cost of materials and supplies.	$5.00 per establishment.
Additional inspection fees	Following any regular inspection, an additional fee will be charged if a follow-up inspection is required.	$25.00

Amount of fees - The amount of fees shall not be more than the cost of administrating this ordinance.