Fillable CONSUMER PROTECTION SERVICES APPLICATION CONTRA COSTA (Contra Costa Health Services)

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CONSUMER PROTECTION SERVICES APPLICATION CONTRA COSTA (Contra Costa Health Services)

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  • 37 check-boxes
  • 44 other fields

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File type: PDF

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
CONSUMER PROTECTION SERVICES APPLICATION
APPLICATION FEE IS NON-REFUNDABLE (SERVICE FEES ARE ADDITIONAL REFER TO FEE SCHEDULE)
OWNER NAME (As it appears on Driver’s License or Federal Tax I.D.):
OWNERS DRIVER’S LICENSE #:
OWNERS SOCIAL SECURITY #:
LIST ADDITIONAL PARTNERS:
OWNER ADDRESS:
FEDERAL TAX ID # (If Corporation):
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
OWNER MAILING ADDRESS (If different from above):
EMAIL ADDRESS:
IN CARE OF: (Billing office or person in charge):
CITY/STATE/ZIP CODE:
FACILITY NAME:
FACILITY PHONE #:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
1. TYPE OF FACILITY: (Please check one)
Restaurant
______ # seats Remote Food Storage Commissary-Vehicle
Event Center
Vending Machines Food Demonstrator
Farm Stand Pool / Spa
School Cafeteria/Satellite
Additional Pool / Spa #______
Limited/Intermittent Use
______ # sq. ft.
______ # sq. ft.
______ # machines
Recreational Water Park
2. SERVICES REQUESTED: (Please check one)
Consultation
Name: _______________________________________________ Phone #: _______________________
Name: _______________________________________________ Phone #: _______________________
Previous Owner: _______________________________________________
Previous Name: _______________________________________________
Site Evaluation
Add Partner:
Drop Partner:
Change of Ownership:
Change of Business Name:
Change of Address:
Previous Address: _______________________________________________
Mailing Owner Billing / Management Company
The undersigned hereby applies for a Permit to Operate and agrees to operate in accordance with all applicable state and local regulations, laws, and such inspection
procedures needed to ensure compliance. Payment of the required fee and late penalties, if any, to secure a valid permit is required before commencing or continuing
operations. Failure to do so may result in a misdemeanor citation, infractions, permit suspension/revocation proceedings, and/or closure. Notify Contra Costa
Environmental Health of any changes in the type of business activity, name, billing address, or ownership by calling the number above.
PERMITS ARE NOT TRANSFERABLE.
APPLICANT NAME: (Please print) _________________________________________________________________
Signature of Applicant: _______________________________________________ Date: _______________
FOR OFFICE USE ONLY
PR #
P/E:
AR #:
REHS:
SUPERVISOR:
RECEIVED BY:
DATE RECEIVED:
AMOUNT DUE:
$
AMOUNT PAID:
$
CHECK #:
CASH
CREDIT CARD:
MC
VISA
RECEIPT #:
XR
CPS APP 8/19
OWNERS EMAIL ADDRESS:
Retail Food Market
Bakery
Incidental Retail Food Market
Cocktail Lounge/Bar (no food service)
Commissary-Carts
CFO - Class A (Direct Sales)
CFO - Class B (3rd Party Sales)
Other: ___________________
Seasonal Fixed Facility
Charitable Feeding
Catering Operation
Host Facility
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CONSUMER PROTECTION SERVICES APPLICATION CONTRA COSTA (Contra Costa Health Services)

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Completed 9 February 2021

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