EmailMeForm
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
Business Name
*
Name of Food Service Establishment
Street Address
*
Exact Street Address and physical location in Columbia, TN
Owner/Manager Name
*
Enter First then Last Name (ex. John Doe)
Contact Information
Business Phone
*
###
-
###
-
####
Email Address
*
REQUIRED: Confirmation will be sent by email.
Mailing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Enter complete Mailing Address even if same as Street Address
Operational Information:
Please complete the following information to describe the establishment.
Was a previous business located at this street address?
Business Name
Owner
Previous Business Was:
About Your Business:
*
Type
Select best description from list
Restaurant
Store with Food Service
Caterer
Bakery
School Cafeteria
Hotel with Food/Breakfast
Daycare
Church
Mobile Kiosk
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
*
MM
/
DD
/
YYYY
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)
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours of Business (Include AM, PM, or CLOSED)
*
Hours
Monday - Friday
Saturday
Sunday
Peak Hours of Operation
*
Equipment Information (Check all that are present)
*
Disposable Dishes
Washable Dishes / Pans
Dishwasher
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
Not sure
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):
*
Gallons
Pounds
N/A
Do you have tools to remove the Interceptor or Trap lids?
*
Yes
No
Will Purchase
I don't know
Not Applicable
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?
*
Yes
No
FSE materials and log forms are available on our website, http://www.columbiatn.com/FOG/FSE.htm
Are oil & grease emulsifiers being used?
*
Yes
No
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!
More Details:
Certification of Information
All the information provided herein is true and correct to the best of my knowledge.
Signature
*
Clear
Print Signature Name
*
Job Title or Position with Business
*
Press Submit to finish! Thank you for completing the Columbia Wastewater FSE Questionnaire!
Powered by
EMF
Form Builder
Report Abuse
