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COLES COUNTY HEALTH DEPARTMENT 825 18th Street P. O. Box 415 Charleston IL 61920 FOR OFFICE USE ONLY Establishment CK/CH/MO 217 348-0530 /www. co. coles. il.us/cchd/index. html APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT please fill-out completely including signature PERMIT TYPE AND FEE check one 2. COLES COUNTY HEALTH DEPARTMENT 825 18th Street P. O. Box 415 Charleston IL 61920 FOR OFFICE USE ONLY Establishment CK/CH/MO 217 348-0530 /www. co. coles. il*us/cchd/index. html APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT please fill-out completely including signature PERMIT TYPE AND FEE check one 2. Category 1. Non-profit organizations. PLEASE COMPLETE FRONT AND BACK OF FORM Name of Establishment 250. 00 No Charge Date Address of Establishment City Mailing Address of Establishment Zip Operator or Manager Emergency Phone Number Individual Firm Corporation Partnership Food Service Headquarters Street State Chief Executive Officer If partnership full names and complete addresses of all partners must be attached with this form* Hours of Operation Monday Thursday Tuesday Friday Wednesday Saturday Sunday CERTIFIED FOOD SERVICE SANITATION MANAGER CATEGORY I ESTABLISHMENT PROVIDE ADDITIONAL NAMES ON BACK OF APPLICATION* Name/Title Number Expiration Date Has this facility changed menu items or food handling practices between October 1 2013 and September 30 2014 Yes No If yes please explain I affirm that the above information is true to my best knowledge and belief* Applicant s Name please print Applicant s Address Inspection of premises made X Applicant s Signature Date Received Approved by Permit issued F WP60 DATA FOOD PERAPP20132014wpd. co. coles. il*us/cchd/index. html APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT please fill-out completely including signature PERMIT TYPE AND FEE check one 2. Category 1. Non-profit organizations. PLEASE COMPLETE FRONT AND BACK OF FORM Name of Establishment 250. Category 1. Non-profit organizations. PLEASE COMPLETE FRONT AND BACK OF FORM Name of Establishment 250. 00 No Charge Date Address of Establishment City Mailing Address of Establishment Zip Operator or Manager Emergency Phone Number Individual Firm Corporation Partnership Food Service Headquarters Street State Chief Executive Officer If partnership full names and complete addresses of all partners must be attached with this form* Hours of Operation Monday Thursday Tuesday Friday Wednesday Saturday Sunday CERTIFIED FOOD SERVICE SANITATION MANAGER CATEGORY I ESTABLISHMENT PROVIDE ADDITIONAL NAMES ON BACK OF APPLICATION* Name/Title Number Expiration Date Has this facility changed menu items or food handling practices between October 1 2013 and September 30 2014 Yes No If yes please explain I affirm that the above information is true to my best knowledge and belief* Applicant s Name please print Applicant s Address Inspection of premises made X Applicant s Signature Date Received Approved by Permit issued F WP60 DATA FOOD PERAPP20132014wpd.

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