Application for License and Inspection Fee
Application is hereby made for a license to operate. By this application it is agreed that the establishment will comply with the provisions of Springfield Township Health Department Rules and Regulations applicable to this type of establishment. It is further agreed that said establishment shall be open to inspection by the Springfield Township Health Department. Any changes in application, owner / manager must contact Health Office (eg. Vendor change, frequency of trash pick-up, etc.) Contractors must be registered and obtain necessary permits with Springfield Township in order to work in your establishment.
Application for license renewal shall be made at least one month before expiration of existing license. The license is not transferable. Failure to submit application prior to expiration, shall result in issuance of citation and fines.
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Complete Lessee Name and Address:
As required by PA Act 62 of 1992, all new establishments applying for license must submit proof that application has been made or receipt has been made acquired of a Sales and Use Tax License or Exemption from the PA Department of Revenue: (check one and upload copy):
, hereby certify that the facts set forth on this application are true and correct to the best of my knowledge.
I understand that the submission of false or misleading information is grounds for legal action.
**If any of your food is prepared off the premises include a copy of the current license and latest inspection of the establishment where the food is prepared, as well as verification by the establishment owner that your food is being prepared there. Your application will not be considered without these documents.