San Bernardino County Health Permit Application
Document Sample
APPLICATION FOR HEALTH PERMIT
Return to:
385 N. Arrowhead Ave. 2nd Floor, San Bernardino 92415-0160 - (800) 442-2283
15900 Smoke Tree St., Ste. 131, Hesperia 92345 - (800) 442-2283
8575 Haven Ave., Ste. 130, Rancho Cucamonga 91730 - (800) 442-2283
www.sbcounty.gov/dehs
This Section To Be Completed By Applicant - Please Print - Health Permits Are NOT Transferable
FACILITY INFORMATION
Effective Date of Transfer: Former Facility Name: E-Mail Address:
Facility Name: Care Of:
Address: City: State: Zip:
Phone Number: Alternative Phone Number: Fax Number:
LEGAL OWNER INFORMATION
Owner of Facility: Phone Number:
Address: City: State: Zip:
INVOICE INFORMATION
Mail To: Care Of:
Address: City: State: Zip:
NOTE:
ALL FEES ARE DUE AND PAYABLE PRIOR TO FIRST DAY OF OPERATION. MAKE CHECKS PAYABLE TO: SAN BERNARDINO COUNTY
Application and fee must be submitted prior to operation by any new owner. Failure to pay within 30 days of the first day of operation will result in the
assessment of a delinquent fee.
I shall notify this agency in writing if I transfer ownership, discontinue operation or change billing address. Failure to do so may result in obligation to
pay health services fees and additional penalties.
I HEREBY MAKE APPLICATION FOR HEALTH SERVICES AND PERMIT to establish and/or operate the above mentioned business, use, or services
in accordance with the laws, ordinances, and regulations that are now or may hereinafter be in force by the United States government, the State of
California, and the County of San Bernardino pertaining to the above mentioned business. I hereby consent to all necessary inspections incident to the
issuance of this permit and operation of the business.
I understand that any construction, alteration or repair, including, but not limited to, equipment changes or alterations, a menu change or change in
facility’s method of operation requires EHS review and approval. Initial_______
Signature: Date:
Print Name: Title:
For Office Use Only For Office Use Only For Office Use Only For Office Use Only For Office Use Only For Office Use Only For Office Use Only
Fee: Late Fee: Total Fee Due: Amount Paid:
Received By: Date: Check Number: EHS Receipt Number:
ENVISION INFORMATION
*FA Number: *PR Number: SR Number: PE Number:
FEES
OW Number: Permit Exp. Date: District Number: City Code:
AR Number: Designated Employee: Contributor Number:
Circle One: Envision Entered By: Date:
New Transfer Renewal
Page 1 of 2 7/17/12
Seating Capacity:________________________________________
FACILITIES
or Number of Soft Serve/Yogurt Machines:___________________________
FOOD
Square Footage:_________________________________________
or
Number of Beds:_________________________________________ Number of Vending Machine Units:_______________________________
Vehicle - Food Vehicle - Vehicle – Pre-packaged Food Preparation Prepackaged Mobile Support
Preparation Pre-packaged PHF Non PHF Cart Food Cart Unit
___ Hot Truck ___ Ice Cream Truck ___ Produce Truck ___ Hot Dog Cart ___ Ice Cream Cart
___ Coffee Truck ___ Catering (Cold) ___ Other ___ Coffee Cart ___ Other
Truck
MOBILE FOOD FACILITIES
___ Other ___ Other
___ Other
(MFF)
Do you operate in an unincorporated County area? Yes No
Mobile Food Facilities operating in unincorporated County areas must obtain approval from County Planning Dept.
List License #, License Plate #, Make, Year, and Decal # below:
DRIVER’S LICENSE NUMBER LICENSE PLATE NUMBER MAKE YEAR DECAL #
______________________________________________________________________________________________________________________________
Commissary Information:
Form A (Inside San Bernardino County) Form B (Outside San Bernardino County)
(POOLS/SPAS)
Number of Pools:_________________ Number of Wading Pools:_______________ Number of Swim Beaches:_______________
REC. HEALTH
Number of Spas:_________________ Number of Water Slides:________________
HOUSING
Number of Units:_________________________________________________
Multi-family dwellings in the unincorporated County areas have been provided information to obtain a County Business License.
VECTOR
Number of Birds:_______________________________ Number of Horses:________________________________
WATER
Number of Connections:_______________________________
CERTIFICATION
BACKFLOW
Tester Only
Commercial List
List License #, Make, Year, Decal # and Number of Gallons below:
LIQUID WASTE
HAULERS
LICENSE NUMBER MAKE YEAR DECAL # NUMBER OF GALLONS
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Type of Facility: Activities (indicate all that apply):
PERMANENT
TATTOOING,
COSMETICS
PIERCING
Tattooing Body Piercing Permanent Cosmetics Branding
BODY
Permanent
AND
Mobile
NOTES:
*Leave blank only if this is a new facility
Page 2 of 2 7/17/12
