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Application for Permit to Operate

  1. County Seal (color)

  2. Wyoming County Health Department
    Environmental Division
    5362 Mungers Mill Road, Silver Springs, NY 14550
    Telephone 585-786-8894

    Application for Permit to Operate

  3. Instructions

    Complete all items that apply to your establishment, sign the application and submit at least 21 days prior to the expected opening date/permit expiration date. A late fee of $50 will be added to total fee if not received in appropriate time

  4. Facility Status*

  5. Days of Operation*

  6. Water Supply*

  7. Sewage System*

  8. Permit Type (Primary Operation)*

  9. Food Service Type

    If unsure please contact our office at 786-8894

  10. Catering Operation

  11. Temporary Residence Size

  12. Temporary Food Service Duration

  13. Mobile Food Risk

    If unsure please contact our office at 786-8894

  14. Operations Associated With Temporary Residence Permit

    Choose All that Apply

  15. Recreational Campground Number of Sites

  16. Operations Associated With Recreational Campground Permit

  17. Children's Camp Type

  18. Operations Associated with Children's Camp Permit

  19. Mobile Home Park Sites

  20. Operations For Tattoo / Body Piercing

    Shop Permit Covers One Artist at the facility, additional artists must receive their own certification.

  21. Click the appropriate line and submit copies of the following documentation with the application to document compliance with the Worker's Compensation Law:

    A. Workers Compensation and Disability Coverage Provided

    Workers Compensation

  22. Upload copies of the appropriate documentation of compliance with the Worker's Compensation Law

  23. And
    Disability Insurance

  24. B. Workers Compensation And Disability Insurance Coverage Not Provided

  25. Payments

    Make check payable to the Wyoming County Health Department:
    5362 Mungers Mill Road
    Silver Springs, NY 14550

  26. Note* Payment may be made online by clicking the link. If payment is not made online the form must be printed and mailed to our office with appropriate fee.

  27. Failure to sign this form may delay issuance of your permit to operate. Operation without a valid permit is a violation of the State Sanitary Code.

  28. Leave This Blank:

  29. This field is not part of the form submission.