Borough of Butler Food License Application * Fields in red are required Borough of Butler Food License Application Establishment Trade Name: Establishment Address: Establishment Phone #: Establishment Fax #: Email Address: Owner / Operator: Owner / Operator Address: Owner / Operator Phone #: Name of Certified Food Handler: Name of Certified Food Manager (if applicable): Name of Exterminator: Phone number of Exterminator: Payer Information Billing Name: Address: Address 2: City: State: - - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Code: Daytime Phone: E-mail Address: Payment Information Payment Amount: Select Amount $100.00 - I-A: Non-Seating $50.00 - I-B: Prepackaged $100.00 - I-C: 1-50 Seats $125.00 - I-D: 51-100 Seats $150.00 - I-E: 101+ Seats $200.00 - II: Supermarket $100.00 - III: School $50.00 - IV: Mobile Food $50.00 - V:Temporary (7-days) $20.00 - VI: Vending Prepackaged $5.00 - Gum Ball $40.00 - All Other $0.00 - VII: Non-Profit Payment Method: ACH Payment (e-Check) Convenience Fee: Enter information as it appears on your check (USA Banks Only) Routing Number: Account Number: Re-Enter Account #: Using the following lower portion of a personal check as an example, enter the information that appears at the bottom of your check. Do NOT include any dashes or spaces. Comments: Terms & Conditions: 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. I agree to the above Terms and Conditions.
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