Applicants must submit the completed application form along with a copy of the food safety course certificate and the appropriate money order to the Department of Public Health, Office of Food Protection, 321 University Avenue, Philadelphia, PA 19104. You can submit the form either by mail or in person. For in-person submissions, an appointment is required. Contact the Office of Food Protection at 215-685-7495 for any assistance. Ensure all information is accurate to avoid delays in processing.

Be aware of the validity period for your Food Safety Certificate. Certificates issued in 2024 will expire in 2029. Ensure you renew your certificate before its expiration to remain compliant.

The purpose of this form is to ensure food establishments in Philadelphia have at least one employee certified in food safety. This certification demonstrates that the employee has completed an approved food safety course and understands the necessary practices to ensure public health and safety. By maintaining this certification, food businesses can provide a safer environment for their customers.

• 1. First Name: Enter your first name as it appears on official documents.
• 2. Middle Initial: Provide the initial of your middle name, if applicable.
• 3. Last Name: Enter your last name as it appears on official documents.
• 4. Home Mailing Address: Provide your current home mailing address.
• 5. Floor / Apartment Number / Location: Specify your floor or apartment number, if applicable.
• 6. City: Enter the city where you currently reside.
• 7. State: Provide the state where you currently reside.
• 8. Zip Code: Enter your current residential zip code.
• 9. Email Address: Provide a valid email address for communication purposes.
• 10. Date of Birth: Enter your date of birth in MM/DD/YYYY format.
• 11. Telephone Number: Provide a contact number where you can be reached.
• 12. Work / Establishment Name: Enter the name of your current work establishment.
• 13. Work / Establishment Address: Provide the address of your current work establishment.
• 14. Work / Establishment Zip Code: Enter the zip code of your work establishment's location.
• 15. Work Telephone Number: Provide a contact number for your work establishment.
• 16. Preferred Method of Receipt: Choose whether you'd like the certificate emailed, mailed to your home, or mailed to your work address.

Failure to submit this form may result in non-compliance with food safety regulations, thereby affecting the business operations.

• Legal Consequences: Non-compliance with food safety regulations can result in fines or other legal actions.
• Business Disruption: Your business may face interruptions or shutdowns due to the absence of certified personnel.
• Reputation Damage: Customers may lose trust in your business due to perceived negligence in food safety standards.

• 1. New Certificate Application: Apply for a new certificate if you have recently completed an approved food safety course.
• 2. Replacement Certificate Application: Apply for a replacement if your current certificate is lost or damaged.
• 3. Certificate Renewal: Use this form to renew your certificate before its expiration date.