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2. Business Name*
4. Business Address*
6. City*
7. State*
8. Zip Code*
10. Business Phone Number*
11. Business Fax Number
13. Business Email Address*
15. Business Website*
17. Corporation Name if different than Business Name
19. Mailing Address, if different than Business Address
21. City
22. State
23. Zip Code
25. Type Of Business

    Ex. Individual, Partnership, LLC, Corporation, Non-Profit

27. Description Of Business
29. Empolyer Identification Number (EIN)*
30. Proof of authorization to do business in New York State*
31. Proof of insurance*
33. North American Industry Classification System (NAICS) code*
35. Square Footage of business
37. Number Of Full Time Employees
38. Number Of Part Time Employees
40. Days Of Operation

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
41. Hours Of Operation
    Hours Of Operation Start Time

    —

    Hours Of Operation End Time
43. Is it registered with Mount Vernon Police Department?

    1. Yes
    2. No
45. Is there a security alarm system?

    1. Yes
    2. No
47. Is there a fire alarm system?

    1. Yes
    2. No
49. Is it registered with Mount Vernon Police Department or Fire Department?

    1. Yes
    2. No
51. Is there a fixed extinguisher system?

    1. Yes
    2. No
53. Is it registered with Mount Vernon Fire Department?

    1. Yes
    2. No
55. Are there hazardous/chemical materials onsite?

    1. Yes
    2. No
57. Is there a 209U form filed with the Mount Vernon Fire Department?

    1. Yes
    2. No
59. Is cooking done on the premises?

    1. Yes
    2. No
61. Name of most senior level employee and title in the absence of the business owner.
63. Address of the senior level employee
65. City
66. State
67. Zip Code
69. Email Address of the senior level employee
70. Phone Number of the senior level employee
72. The names of two emergency (after hours) contact persons with phone and e-mails.
74. 1
76. Name
77. Email Address
79. Phone Number
80. Fax Number
82. 2
84. Name
85. Email Address
87. Phone Number
89. Indication that the business wants/does not want to be included in a City business listing

    1. Yes
    2. No
91. If the property is not owned by business owner, the name of landlord or management company, along with address and phone number.
93. Name
94. Email Address
96. Address
98. City
99. State
100. Zip Code
102. Phone Number
104. e-Signature of business owner or representative indicating that information submitted is correct
Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit

* indicates a required field