Registration Flyer

Registered Punping Companies

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Application for Registration

FOOD SERVICE ESTABLISHMENTS (FSE)




1557 FM ROAD 1110 ▪ CLINT, TX 79836 ▪ (915)791-4480 ▪ (915)791-4498 FAX
APPLICATION DATE:            Applying by :                       
BUSINESS CONTACT INFORMATION
Owner Name:
Company Name
Phone | Fax
E-mail
Registered Company Address
City, State and ZipCode
LVWD Acc#
                         

DO YOU HAVE ONE OR MORE OF THE FOLLOWING
Food Grinder None of the above
(prepackaged):
Garbage Disposal: Grease Trap (Under Sink)
Deep Fryer: Grease Interceptor (Outside):
Three Compartment Sink : Exhaust hood cleaning schedule:
Dishwasher: Dry methods to remove grease :


BUSINESS ACTIVITY
Regular Business: Maximum Building Occupancy:
Business Hours Maximum Seating Capacity :
Maximum Meals Per Day :
Minimum Meals Per Day:









Authorized Representative Statemen
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief,true,accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of a fine.
Signtures
Signature:                    
Name and Title:                    
Date: