Docstoc

San Bernardino County Health Permit Application

Document Sample
San Bernardino County Health Permit Application Powered By Docstoc
					                                                       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

				
DOCUMENT INFO
Categories:
Tags:
Stats:
views:1
posted:2/27/2013
language:Latin
pages:2
PermitDocsPrivate PermitDocsPrivate http://
About