Food Service Establishment (FSE) Registration & FOG Permit Renewal Form
BEFORE YOU BEGIN, NOTE:
A valid EMail address is required for this form.
Setup an account or get a free email account at: https://www.google.com/accounts/NewAccount?service=mail
Name of Food Service Establishment
Exact Street Address and physical location in Columbia, TN
Enter First then Last Name (ex. John Doe)
REQUIRED: Confirmation will be sent by email.
State / Province / Region
Postal / Zip Code
Enter complete Mailing Address even if same as Street Address
Please complete the following information to describe the establishment.
Was a previous business located at this street address?
Previous Business Was:
About Your Business:
Select best description from list
Store with Food Service
Hotel with Food/Breakfast
Bed & Breakfast Facility
Other (Describe in Comments)
Select One: NAICS Class (North American Industry Classification System)
Snacks/Beverage Bar - 722515 or 721191: NO frying/grilling, non-alcoholic beverage bars, Bed & Breakfast Facility, Continental breakfast Facility (Most orders are "TO GO", no seating/very limited seating, uses disposable serving containers/utensils)
Limited-Service - 722513 or 722320 : Fast food, Pizza, Pay before eating, May serve alcoholic beverages, Catering (receptions, banquet halls, etc)
Full Service Restaurants - 722511 : Pay after eating, May serve alcoholic beverages
Buffet Style Restaurants - 722514: Steam Tables, self-service food or drink items
Institutions - 722310 : Cafeterias in Schools, Hospitals, Jails, Prisons, etc. (contracted or self-run)
Food Service Establishments are classed as defined by NAICS. For more information, the official U.S. Government web site is http://www.census.gov/eos/www/naics/
Business Opening Date at this Location
Opening date may be the date a prior business opened (if applicable)
CPWS Account Number
Enter the business account number from your Columbia Power & Water System monthly bill.
Days of Operation: (Check all that apply)
Hours of Business (Include AM, PM, or CLOSED)
Monday - Friday
Peak Hours of Operation
Equipment Information (Check all that are present)
Washable Dishes / Pans
Food Disposal or Grinder (in Sink)
Grease Control Information
Help us understand more about grease control efforts practiced by your business.
Do you have a grease interceptor or grease trap installed?
Yes, Grease Interceptor (Underground)
Yes, Grease Trap (Inside)
No, Neither Interceptor or Trap
NOTE: A Grease Traps are usually located inside and connect to dish sinks and/or dishwashers. A Grease Interceptor is larger and normally located underground with manhole type access lids.
What size (capacity) is the Interceptor/Trap?
Enter # of Gallons or Pounds, then select the measurement type shown. If no Interceptor/Trap installed, enter 0 here then select N/A.
Size shown as (Measurement Type):
Do you have tools to remove the Interceptor or Trap lids?
I don't know
Select one. If No Interceptor or Trap installed, select Not Applicable
Will a member at your establishment be available during business hours to open the access lid(s) to the grease interceptor and/or trap?
Yes, multiple people are trained to assist with access to the device
No but we will train our staff to be prepared to assist with accessing the device
None at this time (Be prepared. Train staff on how to remove the lid(s) for proper access)
How often is the Interceptor/Trap pumped and cleaned?
Indicate the number and interval. Examples : Every 2 weeks; Once a month; Once every X (number of) months; Twice a Year; etc
Do you use maintenance logs?
FSE materials and log forms are available on our website, http://www.columbiatn.com/FOG/FSE.htm
Are oil & grease emulsifiers being used?
Comments & Additional Information
If you selected OTHER for your business type, please describe. Use this space to add any comments you find may be helpful to us in reviewing this information. Thank you!
Certification of Information
All the information provided herein is true and correct to the best of my knowledge.
Print Signature Name
Job Title or Position with Business
Press Submit to finish! Thank you for completing the Columbia Wastewater FSE Questionnaire!