COMMUNITY DEVELOPMENT DEPARTMENT
2 Community Blvd.
847-459-2620 Fax 847-459-2656
APPLICATION FOR HEALTH PERMIT
Establishment Name: __________________________________________________________________
(As it will appear on the Permit)
Address: _________________________________________________ Phone______________________
Email: __________________________________________________ Fax ______________________
Website:_________________________________________________
Type of Ownership: Single Proprietor _______ Partnership _______ Corporation/LLC ________
Corporation Name: ___________________________________________________________________
List of Owners: Title Address Phone
(incl. city, zip code)
____________________________________________________________________________________
____________________________________________________________________________________
Establishment Type: __________________________________________________________________
Establishment Assessment: (check one)
Cooking, cooling and reheating Cooking and serving Prepackaged only
Other: _______________
Illinois State Certified Food Service Manager(s):
Name: ______________________________________ Certification #:____________________
______________________________________ ____________________
______________________________________ ____________________
Pest Control Company: ______________________________________ Phone: __________________
___________________________________ ______________________________________________
Applicant’s Name Applicant’s Signature Date
===========================================================================
FOR OFFICE USE ONLY
Date Permit Issued: __________________ Establishment Number: ___________ Risk Level _________
