Fillable Midland Health Department Environmental Health Permit Application A (City of Midland Texas)

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Midland Health Department Environmental Health Permit Application A (City of Midland Texas)

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3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 1 of 7
A permit application must be submitted for each establishment. An incomplete form will not be processed. Failure to secure a
permit before due date of the current year will result in a penalty of 25% per day of the applicable permit fee plus the amount
otherwise due for the permit.
Instructions:
This section of this application concerns the facility owner. The numbered instructions correspond to the numbered fields
(sections) of the form starting on the next page.
1) Check the box th
at best indicates the reason you are applying for a permit
2) Write in today’s date
3) Write one of the following: the name of the sole owner, the business name of the partnership or the names of the
corporation’s officers starting with the President/CEO.
4) DBA is an abbreviation for ‘Doing Business As’. Write the name of the Owner’s business. It is not necessarily the same
name as the regulated facility.
5) Write the address where the primary owner conducts business. This should be the primary owner’s business office
(which could be the permitted facility, a home, a separate office or the corporate mail or local district offices as
appropriate). The Type field is for entering Ave., St., Blvd., etc. The Unit field is for entering the Apt.#, Suite#, etc. If
necessary, write a 2nd address that further specifies the location of the owner. For example, Building A — Fourth Floor.
(It is not necessary to provide detailed directions to the location.)
6) If you want Environmental Health to be able to contact the primary owner at home, write the primary owner’s home
phone number. Also, write the phone number where the primary owner can be reached during normal business hours.
7) Enter the primary owner’s Driver’s License number.
8) Use your company Tax ID.
9) Specify the mailing address of the owner. Also, if this correspondence should be directed to an individual other than the
primary owner, write the name in the “Care of” field.
10) Check the box that best indicates the type of legal ownership.
11) Indicate whether the owner owns just the business or the property as well.
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 2 of 7
Facility Owner Information
Please Print
(1) Transaction Type: Permit Renewal New/Remodeled Facility Reclassification (2) Today’s Date ____ /____ /____
(3) Primary Owner Name _____________________________________________________________
(4) DBA _____________________________________________________________
(5) Primary Owner’s Physical Address Information
(6) Phone ______ - ______ - ________ Ext ________ Alternate Phone ______ - ______ - ________ Ext ________
(7) Driver License Number _____________________________
(8) Tax ID _______________________________
(9) Primary Owner’s Mailing Address Information
(10) Business Type: Sole Owner Partnership Corporation County Agency Federal Agency Home Owner Association
Local Agency State Agency Limited Liability Company
(11) Owner Type: Property Owner Business Owner
Street Pre- Street Street
Number Direction Name Type
_______________ _________ _______________________________________________________ ______________
Post
Direction _________
2
nd
Address __________________________________________________________________
City ______________________________ Stat
e _________ Zip ______________ - _________
Country ______________________________
Check here if the Owner Mailing Address is the same as the Owner’s Physical Address and then specify only that which differ between the two.
Care of ____________________________________________________________________
Postal Address ____________________________________________________________
__________
Postal Address 2______________________________________________________________________
City ______________________________ State
_________ Zip ______________ - _________
Country ______________________________
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 3 of 7
Facility Data Entry Form Instructions
This section of this application concerns the regulated facility’s name and address. The numbered instructions correspond to the
numbered fields (sections) of the form starting on the next page.
(1) Write the name of the facility. For example, specify the name of the restaurant, market, etc.
(2) Write the address where the facility is located. The Type field is for entering Ave., St., Blvd., etc. The Unit field is for
entering the apt.#, suite#, etc. If necessary, write a 2nd address which further specifies the location of the owner. For
example, Building A — Fourth Floor. (It is not necessary to provide detailed directions to the location.)
(3) Specify the mailing address of the facility. Also, if this correspondence or billing should be directed to a certain
individual, write the name in the “Care of” field.
(4) Write the hours of operation for the facility. Specify the days of the week and hours in each day. For example, specify
“Mon-Sat, 9-7”.
(5) Specify the number of employees.
(6) Indicate the sewage disposal method.
(7) Indicate the water source.
(8) Indicate the garbage disposal method.
(9) Indicate the business legal entity type.
(10) Specify the name and address of the person or entity responsible for payment of the Annual Permit Fee.
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 4 of 7
Facility Information
(1) Facility Name ____________________________________________________________________________________________________
(2) Facility Site Address Information
(3) FACILITY Mailing Address Information
(4) Operating Days _______________ Operating Hours ________________
(5) Number of Employees ___________________
(6) Standard OSSF Aerobic OSSF Public Sewer System
(7) Private Well Public Water System
(8) Private Garbage Service Public Garbage Service
(9) Business Code: Sole Owner Partnership Corporation County Agency Federal Agency Home Owner Association
Local Agency State Agency Limited Liability Company
Check here if the Facility Mailing Address is the same as the Primary Owner’s Mailing Address and then specify only that which differ between
the two.
Check here if the Facility Mailing Address is the same as the Facility’s Site Address and then specify only that which differ between the two.
Care of _______________________________________________________________________________
Postal Address ________
_______________________________________________________________________
2
nd
Line _______________________________________________________________________________
City ______________________________ St
ate _________ Zip ______________ - _________
Email address __________________________________________________
______________________________
Check this box if the Facility Site Address is the same as Primary Owner’s Address and then specify only those that differ between the two.
Mail to Care of Na
me _______________________________________________________________________________
Street Pre- Street St
reet
Number Direction Name Type
_______________ _________ _______________________________________________________ ______________
2
nd
Address Line __________________________________________________________________
City ______________________________ St
ate _________ Zip ______________ - _________
Phone ______ - ______ - ________ E
xt ________
Alt. Phone ______ - ______ - ________
Ext ________
Fax Phone ______ - ______ - ________
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 5 of 7
(10) FACILITY Annual Permit Fee Billing Address Information
Send Bills to:
Owner’s Mailing Address
Facility’s Mailing Address
Third Party (Write Below)
Account Payers N
ame _______________________________________________________________________________
Mail to Care of Na
me _______________________________________________________________________________
Address Line 1 _______________________________________________________________________________
Address Line 2 _______________________________________________________________________________
City ______________________________ St
ate _________ Zip ______________ - _________
Country ______________________________
Phone 1 ______ - ______ - ________ Ext
________
Phone 2 ______ - ______ - ________ Ext ________
Fax ______ - ______ - ________ Ext ________
For Office Use Only
Facility ID _______________
District Code _______________ Loc
ation Code _______________ City Code _____________
Business Type ____
Nature of Business _____________________________
_______________________
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 6 of 7
This section of this application concerns the programs regulated at the facility.
Regulated Program Types and A
nnual Permit Fees
This section of the application concerns each of the programs regulated at the facility. Complete a section for each of the
programs that you selected in the checklist above
. If you have more than two regulated programs at your
facility, copy this page before specifying the information.
NOTE: If your fa
cility is regulated for two or more of the same programs, for example, there are two bakeries at your
facility, specify the ‘Program Identifier’ for each. For example, specify ‘Main Bakery’ for the first regulated program
and ‘Cookie Bakery’ for the second regulated program.
Program Identifi
er _____________________________________________________________________
Send correspondence, rec
all notices, etc., to:
Owner Address Facility Address
Emergency Contact Information
Manager’s Name ____________________________________________________________________
Title ____________________________________________________________________
Day Phone ______ - ______ - ________ Ext ________
Night Phone ______ - ______ - ________ Ext ________
Program Identifi
er _____________________________________________________________________
Send correspondence, rec
all notices, etc., to:
Owner Address Facility Address
Emergency Contact Information
Manager’s Name ____________________________________________________________________
Title ____________________________________________________________________
Day Phone ______ - ______ - ________ Ext ________
Night Phone ______ - ______ - ________ Ext ________
Office Use Only: Next Billing Date: ______/________/________
Office Use Only: Next Billing Date: ______/________/________
3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Fax 432.699.6290
Midland Health Department Environmental Health Permit Application
Page 7 of 7
Regulated Program Types and Annual Permit Fees
Check ALL of the
appropriate boxes to indicate what your facility does.
Food Service Establishment (Restaurant, or On-Premises Consumption)
Retail Food Store (Grocery/ Convenience Stores or Off-Premises consumption)
Warehouse Distributors
1 to 5 Employees $150
6 to 10 Employees $200
11 or More Employees $250
Grocery/ Convenience stores add addition fee of $75.00 each if you have:
Deli # of: ________ $75
Bakery # of: ________ $75
Meat Market # of: ________ $75
Kiosk # of: ________ $75
MOBILE FOOD VENDOR $175
SEASONAL (April1-September 30) $105
FARMERS MARKET $50
TEMPORARY PERMIT (14 days or less-Fairs, Carnivals, Circus, Public Exhibits)
$70
DAY CARE FACILITY $100
FOSTER CARE FACILITY $50
AFTER SCHOOL CHILD CARE PROGRAM $50
PER SWIMMING POOL # of: ________ $100
PER SPA # of: ________ $100
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Midland Health Department Environmental Health Permit Application A (City of Midland Texas)

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Completed 23 January 2021

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