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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 100
CONCORD, CA 94520
(925) 608-5500 (925) 608-5502 FAX
www.cchealth.org/eh/
FACILITY EVALUATION APPLICATION
FOOD FACILITY AND PUBLIC POOLS
(FIRST STEP IN POSSIBLE CHANGE OF PERMIT HOLDER)
APPLICATION FEE IS DUE AND NON-REFUNDABLE (SERVICE FEES AND PERMIT FEES ARE ADDITIONAL, REFER TO FEE SCHEDULE)
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
❑ Registered Exempt Retail Market______# sq. ft. ❑ Production Kitchen (Non-Restaurant) ❑ Spray Grounds
❑ Incidental Retail Food Market______# sq. ft. ❑ Farm Stand ❑ Recreational Water Park
❑ Bakery______# sq. ft. ❑ School Cafeteria ❑ Skilled Nursing Facility______# beds
❑ Food Demonstrator ❑ School Satellite ❑ Host Facility
❑ Cocktail Lounge/Bar ❑ Seasonal Fixed Facility ❑ Other: _________________________
❑ Vending Machine
SECTION 2: Contact Information
A. Facility:
PROSPECTIVE FACILITY (BUSINESS) NAME / DBA:
FACILITY ADDRESS:
CITY/STATE/ZIP CODE:
PHONE #:
FAX #:
CURRENT FACILITY (BUSINESS) NAME / DBA:
B. New Permit Holder:
PROSPECTIVE PERMIT HOLDER’S NAME:
❑
Sole Proprietor
❑
Co-Owners
❑
INC
❑
LLC
❑
LP
(Please provide identification or documentation)
MAILING ADDRESS: (MUST BE DIFFERENT FROM FACILITY ADDRESS)
CITY/STATE/ZIP CODE:
FAX #:
EMAIL:
CONTACT FOR INSPECTION:
PHONE #: (IF DIFFERENT FROM ABOVE)
SECTION 3: Attachments with Application
❑Menu (if food facility) ❑Facility Risk Category Questionnaire (if a food facility) ❑Copy of Valid Identification
SECTION 4: Terms/Signature The undersigned hereby certifies all the information provided on this application is true and accurate.
PERMITS ARE NOT TRANSFERABLE
Signature of Applicant: ____________________________________________________ Date: ________________________________________
Applicant Name please print): _______________________________________________________________________________________________
FOR OFFICE USE ONLY
FA#:
PR#:
AR# :
SR#:
P/E:
REHS:
SUPERVISOR:
RECEIVED BY:
DATE RECEIVED:
AMOUNT DUE: $
AMOUNT PAID: $
CHECK #:
CREDIT CARD:
❑
CASH
❑
RECEIPT #: XR
FE APP 2/2020
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FACILITY EVALUATION APPLICATION CONTRA COSTA FOOD FACILITY AND (Contra Costa Health Services)

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Completed 10 January 2021

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