San Mateo County Health Permit Application

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San Mateo County Health Permit Application Powered By Docstoc
					                                                                                                                             Type of Establishment
                                            San Mateo County Health Department
                                            Environmental Health Services Division                                        Bar/Restaurant         Pool/Spa
                                            2000 Alameda de las Pulgas, Suite 100                                         Bed/Breakfast          Retail Food
                                            San Mateo, CA 94403 www.smhealth.org/environ
                                            (650) 372-6200   fax (650) 627-8244                                           Hotel/Motel            Other Food


                                            Environmental Health Application
OWNER #1 INFORMATION:                                                          OWNER #2 INFORMATION /CONTACT (if applicable):

Name:                                                                          Name:

Home Address:                                                                  Home Address:

City/ST/Zip:                                                                   City/ST/Zip:

 Phone #:                                Alt. #                                Phone #:                                  Alt. #

Email Address                                                                  Email Address




FACILITY INFORMATION:                                                           SEND ANNUAL HEALTH PERMIT BILL TO:

Facility Name:                                                                                 Owner 1 address                        Owner 2 address
                                                                                                                                  *other-please specify below
Facility Address:                                                                          Facility Address

 City/ST/Zip                                                                          *

Phone Number:                                          seating capacity of facility                 square footage of retail establishment


             TOBACCO SALES PERMIT CONDITIONS: The permittee or your employee may not sell, give away, or in any way furnish any
             tobacco, cigarette, or cigarette papers or any other preparation of tobacco or instrument that is designed for the smoking or
             ingestion of tobacco or tobacco products to any person who is under the age of 18. The permit must be displayed in a
             prominent location where retail sales of tobacco are conducted.

 NOTIFY ENVIRONMENTAL HEALTH IN WRITING IF BUSINESS CLOSES OR CHANGE OF OWNERSHIP OCCURS
 HEALTH PERMITS ARE NON-TRANSFERRABLE. I/We certify that the above information is true and correct.

Print owner 1                                                     Signature                                                           Date


Print owner 2                                                      Signature                                                          Date

REASON FOR APPLICATION (check all that apply)

      New facility               Tobacco permit                 Stormwater                Change of ownership

      Change of facility name Previous Facility Name                                                     Date of Change

updated 10/17/2012
                                                       FOR OFFICIAL USE ONLY                                FYI ONLY: PLANS SUBMITTED
                                                                                                            01   Full                   05 Fruit NO Vegetables
      Permit fee amount                                                                                     02   Counter                06 No Fruit Yes Vegetables
                                                                                                            03   Specialty              07 No Fruit or Vegetables
Opening Date                                             Date Paid                                          04   Fruit & Vegetables     Inspection Codes
                                                                                                            RISK CATEGORIES
Record ID                                                PGM/ELE                                            1 low
                                                                                                            2 med
                                                                                                            3 high
REHS APPROVAL                                            DATE                                               4 susceptible population or food processing

				
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posted:11/6/2012
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