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Food Application

Department of Health · South Bend, Indiana

Editable official PDF

Edit the agency’s original form, save your draft, attach documents, and review your completed PDF before signing or ordering delivery.

Print and mail service is available for your prepared packet. Review the destination and the agency’s acceptance requirements before ordering. Government payment is separate from document and postage charges.

Applicant fields are mapped to the source PDF. Agency-only fields are reserved.

Official form and instructionsPay the agency directly
Your application steps6 steps · Department of HealthView steps
  1. 1Prepare your answersComplete here

    Edit and save your answers on the official PDF.

    Official source
  2. 2Add supporting documentsComplete here

    Attach the supporting records listed by the agency. Check that every page is legible and complete.

    • Provide proof of previous-year gross food sales, including alcohol.
    • Complete the affidavit of gross sales. Not-for-profits, new establishments and new owners enter $0 as instructed.
  3. 3Review and signPrepare here, finish outside

    Complete each applicable applicant signature after reviewing the full declarations. Required notary, professional and witness signatures remain separate.

  4. 4Choose paymentPrepare here, finish outside

    $85–$425 based on previous-year gross food sales; $3 per mailed address; 100% late fee after January 31. Government fees are separate from the optional prepared PDF and postage. Review the exact amount and recipient before authorizing a check.

    Pay the agency directly
  5. 5Submit or order deliveryPrepare here, finish outside

    Complete the official application and supporting documents. The county online application redirects to the Food Services Payment Form. Confirm applicable total fees and the current receiving floor before sending a mailed packet.

    Official submission instructions
  6. 6Keep your receiptComplete here

    Save your agency confirmation and payment receipt. Track any mailing from My applications. Delivery does not mean the agency approved your application.

Official requirements and sources
  • Food Application

    Original PDF: mapped applicant inputs, retained instructions, fee schedule and office-only areas.

  • County Forms, Permits & Licenses

    Names this DocuSign application under Food Permits; instructs applicants to allow redirection to Food Services Payments after application completion.

  • Current Department of Health fee schedule and payment policy

    Business checks, cashier checks and money orders are accepted by US mail and made payable to St. Joseph County Department of Health; personal checks are not accepted. Card transaction charge is 2.55% or $1.55, whichever is greater.

Complete your application

Required fields are marked *. Fields follow the agency’s published form. Save your work before leaving this page.

Fill in the official form

Select a highlighted blank and type directly. Use Field list for larger controls and any answers that need a continuation page.

Page 1 of 3 · 37 editable blanks
SJCHD-04-100 Revised 10/24/2025 St. Joseph County Department of Health Application for Annual Food Permit PLEASE PRINT. IF APPLYING ONLINE FILL IN ALL BOXES MARKED “REQUIRED” Permit Number: Year Application Valid: Establishment Name: Establishment Address: City: State: IN Zip: Establishment Phone Number: ( Fax:( Establishment’s E-Mail Address: Owner/Operator: Days of Operation: Hours of Operations (Example Mon-Fri) (Example 8am-5pm) Public Water: Yes No Public Sewage: Yes No Square Footage of Establishment Number of employees Type of Business/Ownership: Individual Partnership Corporation Members Owner(s)/ Corporation Name: Owner(s)/ Corporation Address: City: State: Zip: Corporation Telephone Number: (Fax): Permit Type (check one): Food Service Permit OR Retail Food Store Permit Preferred Method to Receive Permit: Mail to Establishment Mail to Owner/Corporation Address *There is a $3.00 mailing charge to be associated with each mailing address* ***After completion, online applicants will be sent to the payment portal. Not for Profits: Disregard the payment link*** Person receiving permit(s) (please print) Signature of person receiving permit(s) Type or Print Name (Owner/Manager) Signature (Owner/Manager) Office Use Employee: New Permit Permit Fee: $ Paid: Renewal Permit Adm. Fee: Transaction #: Interim Permit/Expires: Late Fee: Convenience Fee: $ Total Fees:

Select any highlighted blank to type. A larger copy of the selected question appears here.

Review every page before signing. Professional, agency and notary signature areas stay reserved.Original blank form