385 N Arrowhead Ave, 2nd floor, San Bernardino, CA 92415
Phone: 800.442.2283
Fax: 909.387.4323
Email: EHS.CustomerService@dph.sbcounty.gov
wp.sbcounty.gov/dph/programs/ehs
12/2018 Health Permit Application Page 1 of 2
APPLICATION FOR HEALTH PERMIT
THIS SECTION TO BE COMPLETED BY APPLICANT HEALTH PERMITS ARE NOT TRANSFERABLE
FACILITY INFORMATION
First Date of Operation:
Former Facility Name (if applicable):
Facility Name:
Care Of:
Email:
Address:
City:
State:
Zip:
Phone Number:
Fax Number:
LEGAL OWNER INFORMATION
Owner of Facility:
Phone Number:
Address:
City:
State:
Zip:
INVOICE INFORMATION
Care Of:
Address:
City:
State:
Zip:
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 AM HEREBY APPLYING FOR HEALTH SERVICES AND PERMIT to establish and/or operate the business mentioned above, 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 San Bernardino County pertaining to said business. I hereby consent to all necessary inspections incident to the issuance of this permit
and operation of the business.
Initials 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 Environmental Health Services (EHS) review and approval.
Electronic Signature Only By checking this box, I confirm I am submitting this application electronically and that the
i
nformation on this form is true and correct. I also acknowledge that I have read, understand and accept any terms
and
conditions of this form.
Date:
Signature:
Print Name:
Title:
For Office Use Only
Fee:
FA Number:
Record ID:
Program Identifier:
PE Number:
Late Fee:
Y
N
Designated Employee:
Received By:
Date:
Check One: New Transfer Reactivate
Service Request:
FDA Category:
Plan Checker Initials:
12/2018 Health Permit Application Page 2 of 2
FOOD
FACILITIES
Seating Capacity: or
Squar
e
Footage: or
Number of Limited Health Care Beds:
Number of Soft Serve/Yogurt Machines:
Num
ber of Vending Machine Units:
Catering Host Facility Food Bank Food Pantry
SNACK BARS
Days of Snack Bar Operation (MM/DD/YY to MM/DD/YY): Hours of Snack Bar Operation (indicate AM/PM):
to to
Days of Operation (check all that apply):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Type of Operation:
Prepackaged Food Only Limited Food Preparation (i.e. heat and serve foods) Full Food Preparation
Type of Permit:
Seasonal (Open less than 6 months per calendar year) Annual (Open 6 months or more per calendar year)
MOBILE FOOD FACILITIES (MFF)/SIDEWALK VENDING
Vehicle
Food
Preparation
Vehicle
Prepackaged
PHF
Vehicle
Prepackaged
Non
PHF
Cart
Food
Preparation
Cart
Prepackaged
Food
Mobile
Support
U
nit
Sidewalk
Vendor
Hot Truck
Coffee Truck
Shaved Ice
Truck
Other
Ice Cream Truck
Catering
(Cold)Truck
Other
Produce
Truck
Other
Hot Dog Cart
Coffee
Cart
Other
Ice Cream
Cart
Other
Stationary
Roaming
(walking)
Do you operate in an unincorporated County area?
Yes
No
Mobile Food Facilities operating in unincorporated County areas may be required to obtain a Business License from the Clerk of the Board.
List the following information below.
Driver License Number:
License Plate Number:
VIN Number:
Make:
Year:
Decal Number:
Commissary Information Form A (Inside San Bernardino County) Form B (Outside San Bernardino County)
REC. HEALTH
(POOLS/SPAS)
NUMBER OF
Pools:
Spas:
Wading:
Water Slides:
Swim Beaches:
DETAILS
Program Identifier (i.e. pool at office)
Capacity (gals)
Max Flow Rate (GPM)
Surface Area (ft.
2
)
Max Occupancy (persons)
HOUSING
Number of Units: Camp Capacity (Campers and Staff):
NOTE: 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:
WASTE
HAULERS
License Number:
Make:
Year:
Decal Number:
Gallons (if applicable):
Total Vehicle Count: (Use a separate sheet of paper if necessary)
BODY
ART
Type of Facility
Permanent
Mobile
Activities (Indicate all that apply)
Tattooing Body Piercing Permanent Cosmetics Branding
WASTE
Small Quantity Generator (less than 200 lbs. of medical waste generated per month without onsite treatment)
Small Quantity Generator (less than 200 lbs. of medical waste generated per month with onsite treatment)
Large Quantity Generator (more than 200 lbs. of medical waste generated per month)
Common Storage Facility (storage area shared by more than one Small Quantity Generator)