Fillable APPLICATION FOR HEALTH PERMIT (County of San Bernardino Information Services Dept.)

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APPLICATION FOR HEALTH PERMIT (County of San Bernardino Information Services Dept.)

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BROWSE COUNTY OF SAN BERNARDINO INFORMATION SERVICES DEPT. (CA) FORMS

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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)
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APPLICATION FOR HEALTH PERMIT (County of San Bernardino Information Services Dept.)

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Completed 25 August 2021

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