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Harris County Food Establishment Plan Review Application

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Harris County Food Establishment Plan Review Application Powered By Docstoc
					 Herminia Palacio, M.D., M.P.H.                                                                                      Michael Schaffer, MBA
 Executive Director                                                                                                  Division Director
 2223 West Loop South                                                                                                Environmental Public Health Division
 Houston, Texas 77027                                                                                                101 South Richey, Suite G
                                                                                                                     Pasadena, Texas 77506

                                                ENVIRONMENTAL PUBLIC HEALTH DIVISION
                                  APPLICATION FOR NEW/REMODELED FOOD ESTABLISHMENT

Date:                                                                                                                    Est. No.:
                                              ESTABLISHMENT AND OWNER INFORMATION
Proposed Business Name:
Proposed Business Site Address:                                                         City:                                  Zip Code:
Name to Enter on Permit (e.g., LLC, Inc.):                                                               Corp. ID No.:
Name of Owner or Registered Agent (Individual):
Mailing Address:
                       City:                                                                    State:                         Zip Code:
Owner or Registered Agent Contact Information:
Office Phone No.:                                              Ext.:                     Mobile Phone No.:
Email Address:                                                                                       Driver’s License No.:

I certify that the above information is true and accurate as of the date of this application.
Signature:                                                  Printed Name:                                                    Date:

Plan Submitter Information (if different from the permit holder):
Name:                                                                   Business Name:
Office Phone No.:                                              Ext.:                     Mobile Phone No.:
Email Address:

                                                              (FOR OFFICE USE ONLY)
District:               Inc. City:                        Est. Type:                     Key Map:                            Well/Public

The following plans have been provided:
     Hard Copy                    Electronic Copy                  Room Finish Schedule                  Floor Plan                     Other

                                      (TO BE COMPLETED BY A PRE-OPENING INVESTIGATOR)
                         Status                                 Date                                                                        Insp. Number
             Plans Approved
             Plans returned for corrections

The following information is needed:
     Preopening check list                  Fire Marshall Inspection               Certificate of Occupancy (city)             Call for inspection
     Water utility letter                   Septic letter                          Well approval

Comments:




                       EPH Office: 101 S. Richey, Suite G, Pasadena, TX 77506 Phone: 713-274-6300 FAX:713-274-6375
                                                               www.hcphes.org
  4-12                            White copy – Files; Yellow copy – Owner/Establishment Representative; Pink Copy – Administrative Office

				
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