Workers' Comp and Disability Insurance Requirements for Obtaining a Temporary Food Establishment Permit

Before a NYS Temporary Food Establishment permit can be issued, you must prove compliance with NYS Workers’ Compensation AND Disability Insurance requirements.

If You Maintain Workers' Compensation and Disability Insurance Coverage

The following forms must be submitted with each permit application:

1.  Workers' Compensation (Submit one from this list): 2. Disability Insurance (Submit one from this list):
  1. Form C-105.2 (issued by your insurance carrier)
  2. Form U-26.3 (issued by the State Insurance Fund)
  3. Form SI-12
  4. Form GSI-105.2
  1. Form DB-120.1 (issued by your insurance carrier)
  2. Form DB-155

Where do I get these forms?

Contact your insurance carrier for these forms.

Do I have to submit new forms each time I apply?

Yes, please submit NEW forms with each permit application. We are unable to substitute insurance forms submitted with recent permit applications.

The legal entity named on the insurance forms must match the Legal Operator listed on the permit application.

If You Do Not Maintain Workers' Compensation and/or Disability Insurance Coverage

If you do not maintain this coverage and are exempt from Workers' Compensation and/or Disability coverage, you need to provide a CE-200 Attestation of Exemption Certificate. To obtain this certificate online, follow the instructions below. A CE-200 is required for each Temporary Food Service Establishment permit application. Copies cannot be accepted.

Instructions:

  1. Go to www.wcb.ny.gov/content/main/Employers/Employers.jsp
  2. Select “WC/DB Exemptions” at the bottom of the page, and then select “Request for WC/DB Exemption (Form CE-200)”. To save time in the future, remember your PIN number!
  3. Complete, print and sign the Exemption Certificate. Submit your original CE-200 (not a copy) with your Temporary Food Service Establishment permit application.

You can also request an Exemption Certificate by calling the NYS Workers’ Compensation Board at 866-298-7830. Please note, it can take up to 8 weeks to process this request.

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