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

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

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PO APP 2/2020
Page 1 of 2
CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
PERMIT TO OPERATE APPLICATION
FOOD FACILITY AND PUBLIC POOL
SECTION 1: Type of facility
❑ Restaurant______# seats ❑ Commissary – Vehicle/Carts ❑ Pool / Spa
❑ Retail Food Market______# sq. ft. ❑ Snack Bar ❑ Additional Pool / Spa #______
❑ Charitable Feeding ❑ Production Kitchen (Restaurant) ❑ Recreational Water Park
❑ Incidental Retail Food Market______# sq. ft. ❑ Production Kitchen (Non-Restaurant) ❑ Spray Grounds
❑ Bakery______# sq. ft. ❑ Farm Stand ❑ Recreational Water Park
❑ Food Demonstrator ❑ School Cafeteria ❑ Skilled Nursing Facility______# beds
❑ Cocktail Lounge/Bar ❑ School Satellite ❑ Host Facility
❑ Vending Machine ❑ Seasonal Fixed Facility ❑ Other: _________________________
SECTION 2: Contact Information
(Facility Address and Permit Holder 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 (BUSINESS) NAME / DBA:
ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
PREVIOUS FACILITY NAME / DBA:
B. Facility (Mailing) Address:
ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
C. Permit Holder Address: (Must be different than facility address)
PERMIT HOLDER NAME
ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
D. Accounts Receivable (Invoice) Address:
IN CARE OF (Billing Office or Person in Charge):
ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
E. Email Address: For Official Inspection Reports. Email address that is provided needs to be able to accept email from external
email addresses. (REQUIRED)
PO APP 2/2020
Page 2 of 2
SECTION 3: Verification of Ownership
❑Valid Identification (For Each Co-Owner) ❑Articles of Incorporation/Organization ❑Documents from escrow companies
❑Registration with CA Secretary of State
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 visual acuity in the better eye without correction)
SECTION 5: Permit Mailing Address
❑Facility Address (A) ❑Permit Holder Address (C) ❑Accounts Receivable Address (D)
SECTION 6: Attachments with Application (if required)
❑Production Kitchen/Approved Facility Agreement Completed (for Caterers)
❑Food Facility Permit Exception Registration (Incidental Retail Food Market under 25 square feet)
SECTION 7: Service Requests (Valid Identification Required / Application Fee May Apply)
❑Co-owner Add / Drop Name:_______________________________________________________________________________________
❑Change of Facility (DBA) Name:____________________________________________________________________________________
❑Change of Address:______________________________________________________________________________________________
❑Mailing ❑Permittee ❑Accounts Receivable
SECTION 8: 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 Permit Holder/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.
Signature of Applicant: ___________________________________________ Date_______________________
Applicant Name: (Please print)_______________________________________________________________________
FOR OFFICE USE ONLY
FA#:
PR#:
P/E#:
REHS:
SUPERVISOR:
RECEIVED BY:
DATE RECEIVED:
AR#:
AMOUNT DUE for Inspection Fees:
$
AMOUNT DUE for Permit (Prorated, If needed):
$
TOTAL Amount Due:
$
AMOUNT PAID
$
SR#
CREDIT CARD:
❑
CASH
❑
CHECK
#:
RECEIPT #:
XR
FOR PROGRAM CLERK USE ONLY
❑
INFORMATION MATCHES ENVISION
PROGRAM CLERK INITIALS:
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PERMIT TO OPERATE APPLICATION CONTRA COSTA FOOD FACILITY (Contra Costa Health Services)

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Completed 10 January 2021

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