HomeMy WebLinkAbout2020 PERMITS TO OPERATE A FOOD ESTABLISHMENT AND
PERMIT FEE PAYMENTS ARE NOT TRANSFERABLE
Notify the Bureau of Public Health Protection of any change of
ownership,type of business activity,business name,or billing
address by calling 631-852-5999 Permits become void upon
change of ownership New owners must apply and pay for a new
permit prior to beginning operation Operating without a valid
permit may subject you to legal action,including a hearing,fines
and possible suspension of the operating permit
E NEVILLE,TOWN CLERK ��� x,
SOUTHOLD,HUMAN RES CTR
PO BOX 1179
SOUTHOLD, NY 11971
Southold Town Clerk
DETACH PERMIT HERE AND DISPLAY PROMINENTLY TO THE PUBLIC
Suffolk County Department of Health Services
360 Yaphank Avenue Suite 2A
STEVEN SELLONEJAMESL ARKEN MO MPH,MBA,MSW Yaphank,NY 11980
SUFFOLK COUNTY EXECUTNE TOMCOMMISSIONER
631-852-5999
SUFFOLKCOUNTY www.suffolkcountyny.gov/health
DEPARTMENT OF HEALTH SERVICES
PERMIT Facility ID FA0001557
Account ID AR0009086
TO OPERATE A FOOD ESTABLISHMENT Issued 1/22/2020
SOUTHOLD HUMAN RES CTR
750 PACIFIC ST
MATTITUCK, NY 11952
OWNER NAME TOWN OF SOUTHOLD
Restaurant Seats=0 Permit ID Number: PT0001350 Mechanical Dishwasher Required
Exterior Seats=0 Hot&Cold Delivery
Catering Seats=0 Valid From 1/22/2020 To 12/31/2020
Bar Seats=0
Total Seats=85
This permit will expire upon the date specified or upon a change of ownership
This permit Is NOT transferrable and Is granted subject to compliance with the provisions of Article 13 of the Suffolk County Sanitary Code and all applicable state,local,
and municipal laws,ordinances,codes,rules,and regulations
THIS PERMIT MUST BE PROMINENTLY DISPLAYED TO THE PUBLIC
Send payment to:
Suffolk County Department of Health Services
360 Yaphank Avenue Suite 2A
Yaphank, NY 11980 II III III III I
SII J IIII II III SII III II IIII Illi IIIII
631-852-5999 § b
www.suffolkcountyny.gov/health
Payable to: Commissioner of Health Services
INVOICE STATEMENT PAYMENT DUE: 12/31/19
TOTAL AMOUNT DUE: $0.00
Permit ID Account ID Invoice ID Facility ID
=1350 AR0009086 �N0022363 [ FA0001557
TO TOWN OF SOUTHOLD
E.NEVILLE,TOWN CLERK Workmen's Comp#
PO BOX 1179
SOUTHOLD, NY 11971 NYS Disability Insurance#:,,, ....
ATTN E.NEVILLE,TOWN CLERK Signature _mmmmm
Mark here if new owner or change in ownership and submit
RE: SOUTHOLD HUMAN RES.CTR. El new permit application with fee.Permits are not transferable.
PLEASE RETURN RENEWAL NOTICE WITH PAYMENT
Renewal Notice
Program/
Date Invoice No, Element Permit No. Desf option Amount
Previous Balance $ 0.00
11/12/19 IN0022363 1901 PT0001350 Annual Permit Renewal for: Food for Aged -RCI $ 63000
11/12/19 IN0022363 9990 Annual Permit Renewal for: FEE EXEMPT DISCOUNT $ (630 00)
Total Amount Due: $0.00
INVOICETHIS
NOTICEPERMIT TO OPERATE;A FOOD ESTABLISHMENT. COMPLETE
4j= TrFFTP, LTION ANTHE TOP SECTION AND RETURNDUE. THE COMPLETED RENEWAL
RECEIVED .
RECEIVED
W,I 2 2019
Southold ler
Your Account's Information As of 11/12/2019
5005 wr irpt.