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2. A valid email address is required for this form.
4. Business Name*
6. Street Address*
8. Owner / Manager Name*
10. Business Phone Number*
11. Email Address
    Confirmation will be sent by email.
13. Mailing Address*
    Complete even if same as Street Address.
15. City*
16. State*
17. Zip Code*
19. Was a previous business located at this address?*

    1. Yes
    2. No
21. Previous Business Name
23. Previous Business Info
25. Type of Business*
    -- Select One --BakeryBed and Breakfast FacilityCatererChurchDaycareHotel with Food/BreakfastMobile KioskRestaurantSchool CafeteriaStore with Food ServiceOther
27. Other Business Type
29. North American Industry Classification System( NAICS) Class

    Food Service Establishments are classed as defined by NAICS. For more information, the official U.S. Government web site is https://www.census.gov/eos/www/naics/

    1. Buffet Style Restaurants - 722514: Steam tables, self-service food or drink items
    2. Full Service Restaurants - 722511: Pay after eating, may serve alcoholic beverages
    3. Institutions - 722310: Cafeterias in schools, hospitals, jails, prisons, etc. (contracted or self-run)
    4. Limited-Service - 722513 or 722320: Fast food, pizza, pay before eating, may serve alcoholic beverages, catering (receptions, banquet halls, etc)
    5. Snacks/Beverage Bar - 722515 or 721191: No frying/grilling, non-alcoholic beverage bars, bed and breakfast facility, continental breakfast facility (most orders are "to go", no /limited seating)
31. Business Opening Date*
    Business Opening Date
32. Days of Operation*

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
34. Monday through Friday Hours*
36. Saturday Hours*
38. Sunday Hours*
40. Peak Hours of Operation*
42. Equipment Information*

    1. Dishwasher
    2. Disposable Dishes
    3. Food Disposal or Grinder (in Sink)
    4. Washable Dishes/Pans
43. Do you have a grease interceptor or grease trap installed?*

    1. Yes, Grease Interceptor (Underground)
    2. Yes, Grease Trap (Inside)
    3. No, Neither Interceptor or Trap
    4. Not sure
45. What size (capacity) is the interceptor or trap?*
    Enter number of Gallons or Pounds, then select the measurement type shown. If no interceptor or trap is installed, enter 0 here then select N/A for measurement type.
46. Measurement Type*

    1. Gallons
    2. Pounds
    3. N/A
48. Do you have tools to remove the interceptor or trap lids?*

    1. Yes
    2. No
    3. I don't know

    1. Not Applicable
    2. Will Purchase
50. Will a member at your establishment be available during business hours to open the access lid(s) to the grease interceptor and/or trap?*

    1. Yes, multiple people are trained to assist with access to the device
    2. No, but we will train our staff to be prepared to assist with accessing the device
    3. None at this time (Be prepared. Train staff on how to remove the lid(s) for proper access)
52. How often is the interceptor/trap pumped and cleaned?*
54. Do you use maintenance logs?*

    1. Yes
    2. No
55. FSE materials and log forms are available on our FSE page.
    Food Service Establishments Page
57. Are oil & grease emulsifiers being used?*

    1. Yes
    2. No
59. Comments & Additional Information
    Use this space to add any comments you find may be helpful to us in reviewing this information. Thank you!
61. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

    1. I agree
63. Print Signature Name*
65. Job Title or Position with Business*
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field