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FACILITY EVALUATION APPLICATION CONTRA COSTA FOOD FACILITY AND (Contra Costa Health Services)

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD,
CA 94520
(925)
692-2500 (925) 692-2502 FAX
www.cchealth.org/eh/
FACILITY EVALUATION APPLICATION
FOOD FACILITY AND PUBLIC POOLS
(FIRST STEP IN POSSIBLE CHANGE OF OWNERSHIP)
APPLICATION FEE IS DUE AND NON-REFUNDABLE (SERVICE FEES ARE ADDITIONAL, REFER TO FEE SCHEDULE)
SECTION 1: Type of facility
Restaurant______# seats Commissary – Vehicle Seasonal Fixed Facility
Retail Food Market______# sq. ft. Commissary – Carts CFO – Class A (Direct Sales)
Registered Exempt Retail Market______# sq. ft. Commissary - Catering CFO – Class B (3
rd
Party Sales)
Incidental Retail Food Market______# sq. ft. Production Kitchen (Restaurant) Pool / Spa
Bakery______# sq. ft. Production Kitchen (Non-Restaurant) Additional Pool / Spa #______
Skilled Nursing Facility______# beds Farm Stand Recreational Water Park
Food Demonstrator School Cafeteria Spray Grounds
Tavern / Cocktail Lounge Bar School Satellite Other: ___________________
Snack Bar
SECTION 2: Contact Information
A. Facility:
PROSPECTIVE FACILITY NAME / DBA:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
CURRENT FACILITY NAME / DBA:
B. N
ew Owner:
(If marking a ownership type; please provide proof)
PROSPECTIVE OWNER NAME :

INC
LLC
LP
CORP
NEW OWNER MAILING ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
EMAIL:
REQUESTER (IF DIFFERENT THAN NEW OWNER):
SECTION 3: Attachments with Application
Menu for Prospective Facility (if food facility)Facility Risk Category Questionnaire (if a food facility) Copy of Valid Identification
SECTION 4: Terms/Signature The undersigned herby certifies all the information provided on this application is true and accurate.
PERMITS ARE NOT TRANSFERABLE
Signature of Applicant: ____________________________________________________ Date: ________________________________________
FA#:
PR#:
AR# :
SR#:
P/E:
REHS:
SUPERVISOR:
RECEIVED BY:
DATE RECEIVED:
AMOUNT DUE:
$
AMOUNT PAID:
$
CHECK #:
CASH
CREDIT CARD:
MC
VISA
D/C
RECEIPT #:
XR
FE APP 1/2017
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FACILITY EVALUATION APPLICATION CONTRA COSTA FOOD FACILITY AND (Contra Costa Health Services)

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Completed 9 February 2021

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