English - Default eForms Template

Fields marked with an asterisk (*) are mandatory.

Plant and Profile Details

Name of Authorized Operator of Plant

Last Name(required)

First Name(required)

Email Address(required)

(Example: name@example.com)

Confirm Email(required)

(Example: name@example.com).

Plant Number(required)

Plant Name(required)

Reason for Licence Revocation

Describe the change to operation(required)

If other, please specify(required)

Effective Date for Change (yyyy/mm/dd)(required)

Declaration

Notice

Take notice that no person shall carry on a licensed activity or operate a premises where a licensed activity is carried out unless the person holds a licence for the activity issued under the Food Safety and Quality Act, 2001.

Take further notice that it is an offence to contravene the Food Safety and Quality Act, 2001 or its regulations.

I, the undersigned, certify that as of the effective date set out above, no activities requiring a licence issued under Ontario Regulation 465/19: Fish Processing will be carried out at my operation. I am requesting that the licence for the fish processing operation described above be revoked.

I certify that the information submitted in this consent form is true and correct to the best of my knowledge.(required)

Name of Authorized Operator of Plant (First and Last Name)(required)

Date (yyyy/mm/dd)(required)

For Office Use Only

Area Manager

Last NameÂ Â

First Name

SignatureÂ *Â Â

Date (yyyy/mm/dd)Â *Â

Summary

Note: To make changes to the information below, please click the “Back” button (at the top of this page) to access previous pages or “Edit Section” to make corrections.

Consent to Revoke a Licence