Required fields are marked with asterisks (*)

New Food Premises Notification Form

The Health Protection and Promotion Act (1990) requires that anyone who intends to open a food premise must notify the Medical Officer of Health and all food premises must be in compliance with the Ontario Food Premises Regulation 493/17.

Please complete this form and submit a copy of the proposed floor plan.

Food Premise Information

Premise Name

Street Address

City

Postal Code

Phone Number

If you were provided with a CSR reference number, please include it here.

Type of Premise

Restaurant

Take out

Caterer

Home-Based Business

Cafeteria

Other

Retail

Private Water System

Yes

Owner Information

Owner Name

Owner Address

Phone Number

Email Address

Opening Information

Intended Opening Date

Floor Plan

Please upload a copy of the proposed floor plan

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Note: Food premises serviced by private water supplies are subject to the requirements of the Safe Drinking Water Act, 2002 and its accompanying Regulations. Private sewage systems are subject to the requirements of Part VIII of the Ontario. Please contact the respective township for Part VIII private sewage systems.

City of Cambridge

City of Kitchener

City of Waterloo

Township of North Dumfries

Township of Wellesley

Township of Wilmot

Township of Woolwich