Fillable 2017 2018 APPLICATION FOR PERMIT TO OPERATE 2 18 2021 (Sacramento County, California)

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2017 2018 APPLICATION FOR PERMIT TO OPERATE 2 18 2021 (Sacramento County, California)

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Environmental Management
Department
Marie Woodin, Director
11080 White Rock Road, Ste. 200 • Rancho Cordova, California 95670 • fax (916) 875-8513
Environmental Compliance (916) 875-8550 ● Environmental Health (916) 875-8440
www.saccounty.net • www.emd.saccounty.net
APPLICATION FOR PERMIT TO OPERATE
FACILITY
Business Name (DBA): Phone:
Site / Commissary Address: City: State: Zip:
Days of operation:
Hours of operation:
If this facility has a semi-frozen (soft serve) processing machine please call the State of California Milk & Dairy Food Safety Branch at (209) 466-7186
BILL
Phone:
Billing Address:
City:
State:
Zip:
OWNER
Owner Name:
Phone:
Address (home or office): City: State: Zip:
Owner E-mail:
Business E-mail:
TYPE OF PERMIT
FEE
PE
TYPE OF PERMIT
FEE
PE
RESTAURANT*
$1292.00
1622
SWAP MEET PRE-PKG FOOD STAND
$150.00
1648
BAR
815.00
1620
ADMIN REVIEW/CONFIRMATION
73.00
1649
RESTAURANT W/BAR*
1665.00
1621
COMMISSARY*
534.00
1680
FOOD PREP ESTAB W/O HOOD <2000 SQ FT*
1014.00
1623
SEASONAL LOW RISK
244.00
1675
SCHOOL/NONPROFIT SR. MEAL PROGRAM
686.00
1625
SEASONAL HIGH RISK
298.00
1676
SCHOOL SATELLITE FACILITY
496.00
1626
SEASONAL RESTAURANT
869.00
1603
FOOD PANTRIES/CLOSETS
181.00
1690
BAKERY – NO PREPARATION
568.00
1652
SATELLITE FOOD DISTRIBUTION FACILITY
239.00
1693
HOST FACILITY CATEGORY A
73.00
1686
RETAIL MARKET (OVER 15,000 SQ. FT.)
1091.00
1614
HOST FACILITY CATEGORY B
365.00
1687
RETAIL MARKET (6,000 – 14,999 SQ FT.)
933.00
1613
RESTRICTED FOOD SERVICE ESTABLISHMENT
630.00
1681
RETAIL MARKET (LESS THAN 6,000 SQ. FT.)
619.00
1612
STORMWATER
83.00
6770
RETAIL MARKET
(25-300 SQ FT PRE-PACKAGED, NON PHF)
365.00
1611
*Add one stormwater fee if any of the following permits are applied for:
VETERAN’S ORGANIZATION FOOD FACILITY*
842.00
1609
1603, 1609, 1621, 1622, 1623 or 1680. One stormwater fee per facility.
CERTIFIED FARMERS’ MARKET
933.00
1619
MOBILE FOOD FACILITY CATEGORY A
190.00
1631
BUSINESS RECYCLING No fee
(All fixed facilities in the City of Sacramento and Unincorporated County)
4CR4
MOBILE FOOD FACILITY CATEGORY B
381.00
1632
MOBILE FOOD FACILITY CATEGORY C
378.00
1633
MOBILE FOOD FACILITY CATEGORY D
670.00
1635
SWIM POOL
$490.00
3611
MULTI-EVENT VENDOR – LOW RISK
322.00
1662
SPA POOL
416.00
3612
MULTI EVENT VENDOR – HIGH RISK
483.00
1663
POOLS ON SINGLE RECIRCULATING SYSTEM
533.00
3613
SECONDARY OPERATOR
268.00
1682
WADING POOL
321.00
3615
CATERING OPERATION
391.00
1683
TEMPORARILY INACTIVE
200.00
3617
OTHER
SPRAY GROUND
375.00
3618
I hereby certify that I am the owner, or authorized representative of the owner, and this business will comply with all State and local laws now in force or which may
hereafter be enacted pertaining to this business.
Print
Title/Position
Date
Multiple Food or Swim/Spa Facility: 100% of highest prescribed fee, plus 92% of each remaining fee. Secondary/Catering Operation (1682, 1683), Swap Meet Prepackaged Food
Stand (1648), Satellite Food Distribution Facility (1693), Mobile Food Facility (1631, 1632, 1633, 1635) are not included as multiples and shall pay the standard fees.
OFFICIAL USE ONLY
EMD RECEIPT#:
AMOUNT PAID:
DATE PAID:
ACCOUNT #:
NEW FACILITY
CHANGE OF OWNERSHIP
ANNIVERSARY DATE (date of ownership change/opening date):
FACILITY ID #:
CT:
SPECIALIST:
PREVIOUS NAME OF FACILITY/BUSINESS:
PREVIOUS OWNER’S NAME:
OW #:
OLD AR #:
PROGRAM RECORD #:
VEHICLE LIC. #:
DECAL #:
RESTRICTIONS/COMMENTS:
APPROVED
DISAPPROVED
BY:
DATE:
W:\Data\FORMSARCHIVE\EHD\ADMIN SUPPORT FORMS\FISCAL YEAR FORMS UPDATE\2017-2018 FEE FORMS\2017 2018 APPLICATION FOR PERMIT TO OPERATE 8 23 2019.docx DOC TYPE: APPLICATION FOR PERMIT
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2017 2018 APPLICATION FOR PERMIT TO OPERATE 2 18 2021 (Sacramento County, California)

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Completed 15 June 2021

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