Warehouse)
Michigan Department of Agriculture and Rural Development
New Food Establishment Application
P.O. BOX 30776
LANSING MI 48909-8276
Phone: 517-284-5771 Email: [email protected]
In Accordance with Public Act No. 92 of 2000, as amended
Mobile Food Commissary
Food Warehouse
Temporary Food Establishment
Retail Food Establishment
Extended Retail Food Establishment
Office Use Only
Temp #:
Inspector Initials:
Inspected On:
STEP 2: BUSINESS INFORMATION
I hereby verify and affirm that all information contained in this application is true and accurate.
Signature:
* Please note that all fields marked with an asterisk (*) are required and must be completed in order to process your license application
**
Please note Federal Identification Number is not required for Individual Ownership Types
STEP 1: ORGANIZATION INFORMATION
*Ownership Type:
Corporation
Sole Proprietor
Limited Liability Co.
Joint Tenant
Partnership
Individual
*Ownership Name:
**Federal Identification #:
Email Address:
*Mailing Address:
*City:
*State:
*Zip:
*Business Name:
*Address:
*City:
*State:
*Zip:
*County:
STEP 3: CONTACT INFORMATION
*Primary Contact Name:
*Phone:
Email:
*Address:
*City:
*State:
*Zip:
*Country:
v
Michigan Resident Agent Required if Organization & Previous contact addresses are outside the State of Michigan
Additional Contact Name:
Phone:
Email:
Address:
City:
State:
Zip:
Country:
STEP 4: LICENSE DETAILS
*Seasonal Agricultural Business? (Select One):
Yes
No
*Do you conduct wholesale sales of shellfish (Select One):
Yes
No
(Only Required for Food Warehouse)
STEP 5: FOOD ESTABLISHMENT FEES (Nonrefundable) - Make check/money orders payable to the State of Michigan
Food Warehouse: $186.00 (1438)
Retail Food Establishment: $186.00 (1430)
Extended Retail Food Establishment: $471.00 (1431)
Mobile Food Commissary: $192.00 (1437)
Temporary Food Establishment: $73.00 (2435)
Shellfish Certification: $150.00 (1412)
