Application for License and Inspection Fee

Application is hereby made for a license to oprate. By this application it is agreed taht 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 transferrable. Failure to submit application prior to expiration, shall result in issuance of citation and fines.

To print out a paper copy of this form please click here.

Month

Establishment

Name

Street Address

Street Address Line 2

City

State

Zip

Establishment Telephone

Proprietor's

First Name

Last Name

Address

Address Line 2

City

State

Zip

Telephone

Email Address

Establishment Details

Manager's Name

Number of Seats

Establishment Hours

Estimated # of Patrons per Day

Total Number of Employees

Size of Establishment in Square Feet *

Fee

Do you have a certified Food Manager?

Yes No

Name

CFM Certificate Number

Expiration Date

Upload a copy of Certificate

Upload

Establishment Requirements

Grease Trap Cleaner

Name

Phone Number

How often are the traps cleaned?

Exhaust hood / filters cleaning frequency

Commercial Cleaning Company

Name

Phone Number

Private Garbage / Refuse Collector

Name

Address

How often are collections made?

Recycling Collector

Name

Address

How often are collections made?

Commercial Establishments are required to recycle according to Recyc & Waste (ACT PA 101)

Exterminating Service

Name

Address

How often are establishments exterminated

Plumbing Contractor

Name

Phone Number

Is the Plumber registered to work in Springfield?

Yes No

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):

Sales & Use Tax License Sales & Use Tax Exemption Certificate Completed Sales Tax Application Annual Mercantile Tax paid

Amount

Upload Copy

Upload

, 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.

Name of Proprietor or Authorized Agent

Title of Proprietor or Authorized Agent

Applicant Email Address *

Date

If ownership is a partnership or corporation attach a list of all partners or corporate officers along with their home addresses and phone numbers.

Upload

**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.

Attach document

Upload

Payment Information

Payment of fees for this application will be requested via email once your submission has been reviewed.  Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.  The amount shown below is an estimated amount and may be adjusted once your submission is reviewed.

Payment Amount Due

Application for License and Inspection Fee

Establishment

Proprietor's

Establishment Details

Establishment Requirements

Grease Trap Cleaner

Commercial Cleaning Company

Private Garbage / Refuse Collector

Recycling Collector

Exterminating Service

Plumbing Contractor

Payment Information

Powered by Versiform

Map Spreadsheet Columns to Import