APPLICATION FOR GIBSON COUNTY
"FOOD SERVICE ESTABLISHMENT LICENSE"
800 S. Prince St.
Princeton, IN 47670
Phone (812) 385-3831 Fax (812) 386-8027

Please Check One: Ten & fewer employees  ____ Eleven & over employees ____
Please Check One: Profit ______ Non Profit (No charge) ______

Fees:
Ten & fewer employees $30
Eleven & over employees $50

NAME OF ESTABLISHMENT: _______________________________________

ADDRESS OF ESTABLISHMENT: ____________________________________

PHONE NUMBER: ________________________________________________

FAX NUMBER: ___________________________________________________

NAME OF OWNER: _______________________________________________

NAME OF MANAGER: _____________________________________________


EXPIRATION DATE OF LICENSE: JANUARY 1ST - DECEMBER 31ST, _______

*** NOTE: Need a license for each establishment.

I agree to comply with the rules and regulations established by the Gibson County Health Department Ordinance No. 2000-7, Ordinance #2006-2 and Ordinance #2007-2.

_____________________
(Signed)

*** Submit Payment to: Gibson County Health Department
For Office Use: 
Ten & fewer employees $30
Eleven & over employees $50
Non Profit (No charge)
 
Permit#: _________________ Amount Paid:________________