Fillable PERMIT TO OPERATE APPLICATION CONTRA COSTA FOOD AND (Contra Costa Health Services)

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PERMIT TO OPERATE APPLICATION CONTRA COSTA FOOD AND (Contra Costa Health Services)

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PO APP 5/2016
Page 1 of 2
CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD, CA 94520
(925) 692-2500 (925) 692-2502 FAX
www.cchealth.org/eh/
PERMIT TO OPERATE APPLICATION
FOOD AND PUBLIC POOL
SECTION 1: Type of facility
Restaurant______# seats Commissary – Vehicle School Cafeteria
Retail Food Market______# sq. ft. Commissary – Carts School Satellite
Registered Exempt Retail Market______# sq. ft. Commissary - Catering CFO – Class A (Direct Sales)
Incidental Retail Food Market______# sq. ft. Production Kitchen (Restaurant) CFO – Class B (3
rd
Party Sales)
Bakery______# sq. ft. Production Kitchen (Non-Restaurant) Pool / Spa
Skilled Nursing Facility______# beds Snack Bar Additional Pool / Spa #______
Vending Machines______# machines Catering Recreational Water Park
Food Demonstrator Farm Stand Spray Grounds
Tavern / Cocktail Lounge Bar Seasonal Fixed Facility Other: ___________________
SECTION 2: Contact Information
(Facility Address and Owner Address must be different addresses.)
A. Facility Address: Is postal mail delivered at the facility? Yes (If yes, please skip Part B) No (If no, please complete Part B)
NEW FACILITY NAME / DBA:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
PREVIOUS FACILITY NAME / DBA:
B. Facility (Mailing) Address:
FACILITY (MAILING) ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
C. Owner (Physical) Address:
NEW OWNER NAME (As it appears on Driver’s License or Federal Tax I.D.):
OWNER ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
D. Accounts Receivable Address:
IN CARE OF (Billing Office or Person in Charge):
ACCOUNTS RECEIVEABLE ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
PO APP 5/2016
Page 2 of 2
E. Email Address: For Official Inspection Reports. Email address that is provided needs to be able to accept email from external email
addresses.
F. Email Address (if different than Part E): For any newsletters involving changes in state law. Email address that is provided needs to
be able to accept email from external email address.
SECTION 3: Verification of Ownership
Sole Proprietorship Articles of Incorporation Articles of Organization
Certificate of Registration with Secretary of State Documents from escrow companies
SECTION 4: Verification of Permit Exemption (if applicable)
Veterans: provide DD214 honorable discharge papers
Charitable or Tax Supported Institutions: provide IRS letter of confirmation as a charitable 501c3 organization
Blind: provide certificate signed by a licensed physician or by the State Bureau of Vocational Rehabilitation that person is blind (having not more than
ten percent cisual acuity in the better eye without correction)
SECTION 5: Attachments with Application
Menu for New Facility (if different from menu submitted with Food and Pool Program Application for Facility Evaluation)
Production Kitchen/Approved Facility Agreement Completed (for Caters)
SECTION 6: Terms/Signature
The undersigned hereby certifies all of the information provided on this application is true and accurate and agrees
to notify Environmental Health Services of any changes that occur including the type of business activity, name,
business location, menu, equipment, billing address, ownership and/or closure.
The undersigned further agrees and understands that any structural alterations, including, but not limited to,
equipment changes or additions requires the submittal of plans and appropriate fee to Environmental Health
Services for review and approval.
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 permit fee and outstanding inspection fee balance, 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.
PERMITS ARE NOT TRANSFERABLE
Signature(s) must be an Owner, Partner or Corporate Officer (Corporation and Limited Liability Companies). A
manually signed copy of this application delivered by facsimile, email, or other electronic transmission shall be
deemed to have the same legal effect as delivery of an original signed copy of this application.
APPLICANT NAME: (Please print)_____________________________________________________________
Signature of Applicant: ___________________________________________ Date_______________________
FOR OFFICE USE ONLY
FA#:
AR#:
P/E:
REHS:
SUPERVISOR:
RECEIVED BY:
DATE RECEIVED:
AMOUNT DUE for Inspection Fees:
$
AMOUNT DUE for Permit (Prorated, If needed):
$
TOTAL Amount Due:
AMOUNT PAID:
$
CASH
CREDIT CARD:
MC
VISA
D/C
CHECK #:
RECEIPT #:
XR
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PERMIT TO OPERATE APPLICATION CONTRA COSTA FOOD AND (Contra Costa Health Services)

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Completed 9 February 2021

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