RETAIL FOOD ESTABLISHMENT HEALTH PERMIT APPLICATION
TO OPERATE WITHIN CHAMPAIGN and/or URBANA, IL
Champaign-Urbana Public Health District
Environmental Health Division
201 W. Kenyon Road, Champaign, IL 61820
Incomplete applications will be returned. Please print legibly.
COMPLETE SECTION ONE:
Establishment Name (DBA)
Health Permit #
Street Address (or Commissary Address, if Using)
City
State
Zip Code
Business Phone Number
Business Fax Number
Business E-mail Address
Illinois Business Tax Number (8-digit sales tax number from IL Dept. of Revenue)
___ ___ ___ ___ – ___ ___ ___ ___ (Ex: 0000--0000)
COMPLETE SECTION TWO:
Operating/Open Days & Times for Offering/Selling/Serving Food/Drink (example: Mon-Fri 8am-4pm / Sat 6am-2pm)
In the past permit year, has your facility changed menu items or food handling practices? Yes No Not Applicable - New Permit
If yes, please explain:
Food/Drink Business Owner Name (1)
Phone Number (for business)
E-mail Address (for business)
Food/Drink Business Owner Name (2)
Phone Number (for business)
E-mail Address (for business)
Name of General Manager of Food/Drink Business
Phone Number (for business)
E-mail Address (for business)
IS THERE A U.S. MAILBOX FOR YOUR BUSINESS AT THE ADDRESS LISTED ABOVE? YES NO
IF NOT, PROVIDE A MAILING ADDRESS BELOW. IF PROVIDED, IS THIS A HOME ADDRESS? YES NO
Business Name
Attention
Business Phone Number
Mailing Address (for business)
City
State
Zip Code
IS THERE A DIFFERENT ADDRESS FOR PERMIT RENEWAL INVOICES? IF SO, LIST IT HERE:
Business Name
Attention
Business Phone Number
Invoice Address (for business)
City
State
Zip Code
I understand that the issuance of this permit/license is conditional upon: (1) compliance with all applicable Champaign-Urbana Public
Health District and City Ordinances and (2) the results of any inspection of the above premises at the current time or any subsequent
time during the period of time this permit/license is in force. I hereby consent to inspection of the permitted/licensed premises by the
Champaign-Urbana Public Health District, City of Champaign personnel and /or City of Urbana personnel.
Signature
Printed Name
Date
THIS SECTION FOR CUPHD USE ONLY:
CUPHD Permit
City of Champaign
City of Urbana
Cash/Credit/Check
$__________
$__________
$__________
__________
Late
Reinstatement
Date Paid
$__________
$__________
__________
Date Issued
Entered in Datab?
DHD?
Date E-mailed
__________
__________
APPLICANT INFORMATION (PLEASE PRINT LEGIBLY) HEALTH PERMIT # _______
UNDER PENALTIES AS PROVIDED BY LAW, I DECLARE THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, THE
INFORMATION ON THIS FORM IS TRUE, CORRECT, AND COMPLETE. I ATTEST THAT I AND ANY OTHER OPERATORS OF
THIS BUSINESS ARE NOT PROHIBITED UNDER ANY STATE, FEDERAL OR LOCAL LAWS OR REGULATIONS FROM OWNING
OR OPERATING A FOOD ESTABLISHMENT OR MOBILE FOOD TRUCK.
____________________________ _________________________ ________________
SIGNATURE OF APPLICANT PRINTED NAME DATE
SUBMIT FORM TO THE CHAMPAIGN-URBANA PUBLIC HEALTH DISTRICT
CHECK ONE: INDIVIDUAL PARTNERSHIP CORPORATION LLC OTHER __________________
CORPORATE NAME _________________________________________________________________
BUSINESS NAME (D/B/A) _____________________________________________________________
BUSINESS ADDRESS ________________________________________________________________
STREET CITY STATE ZIP
IS YOUR BUSINESS THE RECORD TITLE HOLDER FOR THIS BUSINESS ADDRESS? YES NO
BILLING ADDRESS __________________________________________________________________
STREET CITY STATE ZIP
BUSINESS PHONE _______________ BUSINESS FAX ______________ EMAIL _____________________
MANAGERS NAME ______________________ PHONE _____________ EMAIL ____________________
ILLINOIS BUSINESS TAX (IBT) # __ __ __ __ - __ __ __ __ (NOTE: 8-DIGIT SALES TAX NUMBER FROM IL DEPT. OF REVENUE)
DOES YOUR REGISTERED ADDRESS ASSOCIATED WITH YOUR IBT # MATCH THE BUSINESS ADDRESS ABOVE? YES NO
DOES YOUR BUSINESS OPERATE AT MULTIPLE LOCATIONS IN CHAMPAIGN/URBANA? YES NO IF YES, WHAT IS YOUR
LOCATION CODE(S)? _______________________________________________________________________________
ARE ANY MONIES OWED THE CITIES (CHAMPAIGN/URBANA) BY THE APPLICANT (E.G. BILLS, TAXES, LICENSES, ETC.)? YES NO
IF YES, PLEASE INDICATE WHICH CITY, AMOUNT OWED, FOR WHAT PURPOSE AND LENGTH OF TIME OWED: ___________________
________________________________________________________________________________________________
City Food License Application
TO OPERATE A FOOD SERVICE/TAVERN/RETAIL FOOD
ESTABLISHMENT/MOBILE FOOD VENDING WITHIN THE
MUNICIPALITIES OF CHAMPAIGN AND/OR URBANA, ILLINOIS
OWNERS/PARTNERS (PLEASE PROVIDE INFORMATION FOR ALL OWNERS/PARTNERS)
1) OWNERS NAME ______________________ PHONE ______________ EMAIL _________________________
2) OWNERS NAME ______________________ PHONE ______________ EMAIL _________________________
(ATTACH ADDITIONAL SHEET(S) IF NECESSARY)
FOR OFFICE USE ONLY
CITY OF CHAMPAIGN $ _________ DATE RECEIVED ____________ CITY LICENSE # _________
CITY OF URBANA $ _________ DATE ISSUED ____________ CITY BUSINESS # _________
