Food Establishment License Application Michigan Department of Agriculture & Rural Development

Michigan Department of Agriculture &
Rural Development
FI-107 Rev 9/15
P.O. Box 30746, Lansing, MI 48909 • 517-284-5771
In accordance with 2000 Public Act No. 92, as amended.
Food Establishment License Application
No
Temporary Longer
Needed
If Renewal, Unique ID or License No. of Establishment _____________________
License Year Ending: _______Status:
New
Renewal
Business Information
Business Name:
______________________________________________________
Business Address:
______________________________________________________
City:__________________________________________________
State: _____________
County:______________________________________________
Zip:_______________
Blank Space
Business Phone: (________)___________ Business Fax:(________)___________________
For Official Use Only
Business Email:_________________________________________________________
Mailing address if different from above: Street or P.O. Box:___________________________
________________________________________________________________________________________________________
City:_____________________________________ State: ______ County:__________________________ Zip:_______________
Corporate/Owner Information
Ownership Type:
Sole Ownership
Joint Tenant
Partnership
L.L.C.
Corporation
Corporation: ____________________________________________________________________________________________
Owner/President (CEO) Name:__________________________________________________ Date of Birth: _________________
Street Address of Corporation or Owner:_______________________________________________________________________
City:_______________________________________________________________________ State: _______ Zip:_____________
Business Phone: (_____)_____________ Business Fax: (_____)____________ Business Email: _________________________
Federal/Tax ID #
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
License Fees (These fees are effective 10/1/2015 to 9/30/2016; if submitting after 9/30/2016, obtain a new application.)
$43.00 Fee
FTM - Temporary Food
Establishment Operates 14
consecutive days or less
excluding fairs.
AOBJ: 0435
FSF - State or County fair only
AOBJ: 0435
$109.00 Fee
$274.00 Fee
$186.00 Fee
FRF - Retail Food Establishment
AOBJ: 0430
FMC - Mobile Food Commissary (Serving
mobile grocery) AOBJ: 0437
FLP - Limited Wholesale Food
Processor with $25,000.00 or
less in annual gross sales.
AOBJ: 0433
FMF - Mobile Food License – Plate
No. __________________ AOBJ: 0434
$153.00 Fee
FFW - Food Warehouse
AOBJ: 0438
FST - Special Transitory Food Unit (STFU)
AOBJ: 0436 Note: Please call MDARD before
FRE - Extended Retail Food
Establishment (grocery with
both food service and
seating available)
AOBJ: 0431
FFP - Wholesale Food
Processor AOBJ: 0432
submitting a STFU application
New Location – anticipated opening date of business:________________ Is this a seasonal agricultural business:
Yes
No
Payment Method: Check/Money Order No.: ______________________________________ Amount enclosed: _______________
Please make check/money order payable to the State of Michigan and submit to the address at the top of the page.
Signature:__________________________________________________ Date:___________________
Please print your name here:___________________________________________________________
Title:___________________________________________________
www.michigan.gov/mdard-licensing
Establishment Number
Additional Corporate/Joint Tenant/Partnership Information (Need home address/ birthday for each owner)
Ownership Type:
Joint Tenant
Partnership
L.L.C.
Corporation
MI Resident Agent (Corp) :
Date of Birth:
/
/
This application CANNOT be processed without date(s) of birth.
Home Address :__________________________________________________________________________________________
City:_________________________________________ State: _______ County:_______________________ Zip:_____________
Home Phone: (
)
Cell Phone Number: (
)
Additional Corporate/Joint Tenant/Partnership Information (Need home address/birthday for each owner)
Ownership Type:
Joint Tenant
Partnership
L.L.C.
Corporation
Partner A:_______________________________________________________________________Date of Birth____/____/______
This application CANNOT be processed without date(s) of birth.
Home Address:___________________________________________________________________________________________
City:________________________________________ State: _______ County:_________________________ Zip:
_____________
Home Phone: (
)
Cell Phone Number: (
)
Partner B:______________________________________________________________________Date of Birth:____/____/______
This application CANNOT be processed without date(s) of birth.
Home Address:___________________________________________________________________________________________
City:_________________________________________ State: ______ County:_________________________ Zip:_____________
Home Phone: (
)
Cell Phone Number: (
)