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Food Service Facility Registration Form

Note: Fields In Red Are Required

Establishment/Facility Name:

Parcel Number:

Doing Business As:

Only enter a name if it's different than the Establishment Name

Contact Person For Grease Related Issues

Contact Person First Name:

Contact Person Last Name:

Contact Phone:

Contact Email:

Mailing Address Line 1:

Mailing Address Line 2:

Mailing City:

Mailing State:

Mailing Zip Code:

Preferred Contact Method

Secondary Contact Information For Grease Related Issues

Contact Person #2:

Contact Phone:

Contact Email:

Site Address

Site Address Line 1:

Site Address Line 2:

Site City:

Site State:

Site Zip Code:

Food Service Establishment Details

Establishment/Facility Type:

Seating Capacity:

How many days per week of operation:

How many the hours per day of operation:

Grease Removal Systems

How many grease tanks are there:

Do you have a grease maintenance-training program:

Yes No

Grease tanks/traps clleaning/pumping schedule:

Date last cleaned or maintained:

Date last pumped:

Are your maintenance logs and cleaning records available for review:

Yes No

Oil Recycling Program

Do you recycle oil:	Yes No
How many (fry) oil recycling tanks are located on the property:
If applicable, what is the total estimated (fry) oil capacity in gallons: The oil recycling tanks usually have a label on them specifying their size in gallons.
Date last cleaned or maintained:
If applicable, what is the inspected and cleaned/pumping schedule for your fry oil:
Date last pumped:
Are your maintenance logs and cleaning records available for review:	Yes No

Waste Haulers/Recyclers

Grease Removal Provider

or enter name if not found

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone:

Email:

Recycling Removal Provider

or enter name if not found

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone:

Email:

Terms and Electronic Signature Agreement:

The Food Service Facility (FSF) understands and agrees that when hiring a grease waste hauler/maintainer to collect, remove, inspect, dispose, maintain and/or perform any other service to their grease removal systems, that it is their responsibility to verify the grease waste hauler/maintainer is licensed in the State of Florida and is permitted and in good standings to do business in the City of Pembroke Pines.

The FSF understands and agrees to use the City of Pembroke Pines F.O.G. Program to register the required inspection and cleaning/pumping schedules and service reports to stay in compliance with City Ordinance § 50.56 REQUIRED USE OF GREASE TRAPS. There is no charge to the FSF, Licensed Inspectors and Service Contractors permitted to do Business in the City of Pembroke Pines to use the City’s F.O.G. Program.

The FSF, Licensed Inspectors and Service Contractors agrees to keep current any licenses and/or permits that may be required by the State of Florida, Broward County, and the City of Pembroke Pines to install, collect, remove, inspect, dispose, maintain and/or perform any other service to the F.O.G. system(s) used in the City of Pembroke Pines.

The FSF understands and agrees to have a representative attend compliance review workshops and to attend subsequent workshops regarding the City's F.O.G. Program.

The FSF, licensed Inspectors and Service Contractors agree to provide electronic credentials to allow the City’s F.O.G. program administration to use these credentials to communicate with them electronically.

I hereby certify that I have provided true, accurate, and complete information to the best of my knowledge and will maintain and promptly update the registration data annually or sooner if needed.

By checking the box and providing my electronic signature below, I accept and agree to the Terms stated above.

I agree.

Printed Name of Applicant

Date