Santa Barbara County Enivronmental Health Permit Application by PermitDocsPrivate

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									                                                                                                               Environmental Health Services
                                                                        225 Camino Del Remedio, Santa Barbara, CA 93110 (805)681-4900 FAX (805)681-4901
                                                                2125 S. Centerpointe Pkwy., Rm. 333 Santa Maria, CA 93455 (805)346-8460 FAX (805)346-8485

                                                             Applica tio n Fo rm
Section #1: Type of Application (Check                     the appropriate box(es)
   New Food Facility: effective date of operation: _____________________________ (Complete sections 2, 3, 4 and 5)
   New Pool/Spa/Wading Facility: effective date: ____________                         Primary and/or        Secondary (Complete sections 2, 3, 4 and 5)
   (Note: An annual State of California surcharge of $6.00 will be collected for each public swimming pool)
   New Owner: effective date: ____________________ (Complete sections 2, 3, 4 and 5)
   Change of Ownership: Added/deleted partner or formed a Corp. or LLC; effective date:___________ (Complete 2, 3, 5)
   Change the name of the business: (Complete sections 2, 3, 4 and 5)
   Change the legal name of the Permittee: (i.e., by incorporation, marriage, court proceedings)(Complete 2, 3, 4 & 5)

Section #2: Owner Information (Please Print)                                                                                         For Department Use Only
 Owner(s): Last _______________________________ First _____________________________
                                                                                                                                Owner ID: OW____________
                 Last _______________________________ First _____________________________
Phone: (___) _____-______ Cell phone: (___) ______-______ Fax: (___) _______-_______ E-mail:_________________
 Mailing/Billing Address: Care of ______________________________________________________________________
              Street/PO Box ______________________________________________________________ Suite                                                         ________
                             City ___________________________________________ State/Zip                                    ______ ________________
    1                   1                                         2                  3                 4                    5                6
     Corporation            Limited Liability Company (LLC)           Sole Owner         Partnership       Local Agency         County           State

 Name of Corporation or Limited Liability Company: _____________________________________________________________________

Section #3: Facility Information (Please Print)                                                                                   For Department Use Only

Business name (DBA):____________________________________________________________                                          Facility ID:   FA ___________________
Business address: _______________________________________________ Suite ____________                                      Location Code: __________________

City __________________________ State C A Zip ________ Business Tele.:(805) -______ _______ Fax: ______ _______ _______

Previous establishment name_____________________________________________________________________________________

What is the source of the water system at this site?                  Private            Public                                     For Department Use Only
Section #4: Specific Program Information (Indicate the type of facility you will be operating
                                                                                                                            Program ID: PR ___________________
and answer the appropriate questions). See fee schedule at www.sbcphd.org/ehs.
    Food Facility - Size _____________ square feet of “total building floor area”, which means any room,
                                                                                                                                           EV ______________
        building, or place, or portion thereof, maintained, used, or operated for the purpose of storing, preparing,
        serving, manufacturing, packaging, transporting, salvaging, or otherwise handling food at the retail                 Employee ID: ____________________
        level.) Fee based on size of facility – see fee schedule.
                                                                                                                             Program Element: ________________
    Food Facility – Low Risk Not to exceed 3,000 square feet of “total building floor area” which means                        Billing Status:
        any room, building, or place, or portion thereof, maintained, used, or operated for the purpose of storing,
        preparing, serving, manufacturing, packaging, transporting, salvaging, or otherwise handling food at the                             (01) Active
        retail level and with inventory limited to commercially prepackaged, nonpotentially hazardous food
                                                                                                                                             (03) Temp inactive
        and/or whole uncut (not ready to eat) produce. Fee $292 [1605]
                                                                                                                                             (04) Active-exempt
    Certified Farmers Market - Produce only. Fee $636 [1620]
    Certified Farmers Market – With potentially hazardous food. Fee $792 [1621]                                            Permit Effective date: __________________

    Satellite Dining Facility – remotely located food service operation that is conducted on the same                      Reviewed by:_________________________
        property as, in reasonable proximity to, and in conjunction with and by, a fully enclosed permanent food
        facility. Fee $176 [1630]
    School Dining Facility – Fee $208 [1632]
                                                                       Page 1 of 2 Pages
    Vending Machine(s) - With potentially hazardous food. Fee $56 [1644]          Statement of Commissary Use Letter attached
How many? ________ Location(s): _______________________________, _____________________________,
___________________________, ___________________________, _____________________________
      Food Vehicle –
          Mobile Food Preparation Unit Fee $328 [1635]
          Mobile Food Facility / Mobile Support Unit ( this includes carts, trucks and others ) Fee $208 [1645]
          o Mobile Support Unit - attach a list of mobile food facility(ies) which will be cleaned and/or serviced by this unit
        Mobile Food Facility – Low Risk ( limited to prepackaged, nonpotentially hazardous or frozen food ) Fee $168 [1638]
Attachments With The Application:
   Statement of Commissary Use letter (if the commissary is not located within Santa Barbara County,          Facility Recall Type (check)
   include a copy of the respective County Health Permit)                                                         B - Bottled /Canned Goods
   Food Vendor Schedule of Stops letter (required for all Food Vehicles)                                          C - Candy
   For Produce: Produce form from the County Agricultural Commissioner’s Office                                   D - Milk/Dairy
                                                                                                                  M - Meat (Beef, Poultry,
   Vehicle Registration (provide copy at the time of submitting application)
                                                                                                                  Pork, Lamb)
   Vehicle License Plate Number ___________________________________                                               O - Oysters and Shellfish
   California Drivers license (provide copy at the time of submitting application)                                P - Produce
                                                                                                                  S - Seafood
Business name of food vehicle: _____________________________________________________                              Menu will remain the same
Seasonal Period: Beginning date: _____________         Ending date: ________________________                      as previous owner
                                                                                                                  Current Menu provided
      Organized Camp - __________________________________________________________
     Pool(s) - Indicate number of each: Pool ____ Spa ____ Wading Pool ____ Special Use Pool ____
Seasonal Period: Beginning date: _______________________   Ending date: _______________________________
   ( A public swimming pool which operates more than three months of the year is not considered a seasonal activity.)
Section #5: Certification
Are you eligible for a veteran’s fee exemption? (yes/no): ______ ;if yes, attach an Affidavit For A Veteran’s Fee Exemption For The Health
Permit To Operate A Food Business (form is available at Environmental Health Service’s offices).
Undersigned hereby certifies all of the information provided on this application is true and accurate. Environmental Health Services will be
notified of any changes which occur in the type of business activity, name, billing address, ownership or closure.
I understand that any structural alterations, including, but not limited to, equipment changes or additions, requires the submittal of plans and
appropriate fee to Environmental Health Services for review and approval prior to opening.
Note: Signature(s) must be original; facsimiles or photocopies are not acceptable for Health Permit application. Signature must be an
Owner(s), Partner(s) or Corporate Officer (Corporation and Limited Liability Companies).
Submission of an application is not a permit to operate until additional steps are completed and authorization is given for a food facility to
process and distribute food products, for example, plan check, consultation and or other departmental approvals may be required.
It is recommended EHS be contacted before purchasing or operating a food facility to request a file review and or schedule a consultation
inspection with the district inspector to assist in evaluating the facilities’ structure and equipment.
Print Name #1_______________________________________________ Title: _____________________________
Signature:      ________________________________________________ Date: ______________________________
Print Name #2_______________________________________________ Title: ______________________________
Signature:      ________________________________________________ Date: ______________________________
Print Name #3_______________________________________________ Title: ______________________________
Signature:      ________________________________________________ Date: ______________________________

                                                  For Department Use Only
 HEALTH PERMIT Fee paid $ ___________ Check #_________Date __________ Receipt #__________ Program/Element _______ By _______
 Comments:
 _____________________________________________________________________________________________________________________
 ROUTE to (initial & date):   Specialist ______________________     Supv ______________________          Clerical ______________________
 Acct.: Invoice # ________________ Date _____________ Amount Billed $ _________________ Initial: __________        Clerical File

EHS 16-1 (Rev. 03/02/12)
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