I affirm that I have completed the statements listed within this form and the information given is full and true and known to be so.
Each license issued under this Article must be prominently displayed on the premises where food sales are being conducted.
This License expires on December 31st. of year year in which it is issued and is not transferable. This license may be revoked by action of the Butler Borough Board of Health for failure to comply with applicable State and Local standards.