Fillable Environmental Health Division (County of Los Angeles / Internal Services Department)

Fill Online, Printable, Fillable, Blank Environmental Health Division (County of Los Angeles / Internal Services Department) Form

Use Fill to complete blank online COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Environmental Health Division (County of Los Angeles / Internal Services Department)

On average this form takes 23 minutes to complete

The Environmental Health Division (County of Los Angeles / Internal Services Department) form is 1 page long and contains:

  • 1 signature
  • 44 check-boxes
  • 67 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of Los Angeles / Internal Services Department

BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
09/2020
Date of Application:
Documents required for submittal: 1. Proof of ownership (i.e., business ownership, seller’s permit);
2. Supplemental Application Form, as required (noted by * below)
This Section to Be Completed by Applicant – Please Print or Type
FACILITY INFORMATION
Select One: New Facility Change of Ownership
TYPE OF FACILITY
(Each facility type requires a separate public health permit/license application)
Animal Keeper*
Boarding Home*
Body Art*
Cannabis*
Commercial Laundry
Certified Farmers Market*
Condominiums
Food Facility*
Garment Manufacturing*
Hotel or Motel*
Interim Housing Facility
Laundry Self-service
Massage Establishment*
Mobile Food Facility*
Public Swimming Pool*
Residential Hotel/Single Room Occupancy
Self-hauler
Sewage Pumper Truck
Solid-waste Facility
Theater
Toilet Rental Agency
Vending Machine*
Waste Collector
Water Systems, Public*
Wiping Rag Business
Other, specify:_____________
Legal Name of Business (DBA):
Business Address: (include street directions and suite number, if applicable)
City:
Zip:
Business Phone Number/s:
Hours of Operation: M: ________ T :________ W: ________ Th: ________ F: ________ Sa: ________ Su: ________ 24 Hrs
LEGAL OWNER(S) INFORMATION
Type of Ownership
(*attach Certificate of LP, LLP Registration, Articles of Incorporation or Organization)
Individual/Sole Proprietorship Partnership LP* LLP* Corporation* LLC*
First Date of Operation:
OWNER 1
Business Owner:
Select one Photo Identification:
(if Sole Proprietorship or Partnership, attach copy of ID)
ID
Number:
Owner's Address: (must be different than Business Address and cannot be a P.O. Box)
Driver License - State: ______
City:
State:
Zip:
ID - State: ______
Owner E-mail:
Owner Telephone:
Consulate ID: _____________
Emergency Contact Name:
Emergency Telephone:
Other, specify: ____________
OWNER 2
Business Owner:
Select one Photo Identification:
(if Sole Proprietorship or Partnership, attach copy of ID)
ID
Number:
Owner's Address:
(must be different than Business Address and cannot be a P.O. Box)
Driver License - State: ______
City:
State:
Zip:
ID - State: ______
Owner E-mail:
Owner Telephone:
Consulate ID: _____________
Emergency Contact:
Emergency Telephone:
Other, specify: ____________
BILLING
Check if billing information is the same as above (Leave blank if you are not the primary owner.)
Billing Contact Name:
Billing Contact Telephone:
Billing Mailing Address:
(include street directions and suite number, if applicable)
City:
State:
Zip:
TERMS
I HEREBY SUBMIT THIS APPLICATION FOR A PUBLIC HEALTH PERMIT/LICENSE to conduct the above-mentioned business, occupation or other activity in accordance with the
laws, ordinances, and regulations that are now or may hereafter be in force pertaining to the above-identified facility. I certify that I am the owner or authorized representative of this
business and that all statements are true to the best of my knowledge. After issuance of the public health permit/license, I hereby consent to all necessary inspections conducted by
the Department of Public Health, Environmental Health Division.
I understand that Public Health Permits/License are not transferable and not refundable. I shall notify this agency in writing if I transfer ownership, discontinue operation or change the
billing address. I understand that failure to do so may result in an obligation to pay additional penalties.
I understand that a failure to maintain a current Public Health Permit/License may result in the closure of the facility, pursuant to California Health and Safety Code and/or applicable
local ordinances.
I underst
and that any construction, alteration or repair, including, but not limited to, equipment changes or alterations, a menu change, or change in method of operation
requires review and approval by Department of Public Health, Environmental Health Division.
Print Name:
Title:
Signature:
Date:
OFFICE USE ONLY
Amount Owed: (to be determined by Specialist on date of approval)
Payment Due By:
SR #:
PE Code:
PE Description:
Billing Status:
Invoice #:
PUBLIC HEALTH PERMIT/LICENSE APPLICATION
Environmental Health Division
5050 Commerce Drive, Baldwin Park, CA 91706
www.publichealth.lacounty.gov/eh
(888) 700-9995
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Environmental Health Division (County of Los Angeles Internal Services Department)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document