Select Private For-Profit Restaurant* and indicate whether or not it is a franchise. *Restaurant is defined as a private for-profit establishment where meals are sold and served to customers, including in-store delis.
Part 2 – Sponsoring Organization or Business
Enter store information, or corporate information if the restaurant is owned by a corporation.
Part 3 – Specific Site Information-Site Where Meals Are Served
Must be filled out completely for each location, include the telephone number. The telephone number will appear on the bottom of the Electronic Benefit Transfer (EBT) receipt. Include store number or franchise under Site Name (e.g., Taco Bell #4217). If more than three sites, list addition sites on a separate sheet of paper and attach using the same format. Enter manager information. Group Living Arrangement does not apply. Note: Information provided in this section will be used in an informational listing. This listing will be distributed to CalFresh recipients and posted online.
Part 4 – Ownership Information
This section applies and must include all owners/officers and spouses. Home address is required.
Part 5 – Business Information
All questions must be answered.
Part 6 – Agreement and Signature Block
An original signature of one of the owners/officers is required. (All owners are NOT required to sign) Print and sign the application.
Attachment A and B – Meal Service Application Required Documentation List Keep Attachments A and B for your records.
Provide all required documentation listed in Section A Include government issued photo identification card and a copy of a Social Security card of owners/officers spouse.
Note: Documentation is not required for publicly-owned corporations.
Copy of the contract with the State agency is the Memorandum of Understanding (MOU).
Copy of a valid business license. (A health permit and business license is required for each location. Must be current and have the correct location address/ownership).
Mail the signed application and MOU with all required supporting documentation to:
Orange County Social Services Agency Attn: Restaurant Meals Program 500 N. State College Blvd., Suite 100 Orange, CA 92868
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