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2. For Health Permit: Please submit with this application a copy of your Driver’s License and a copy of your food manager's certificate. For Alcohol Sales Permit: Please submit with this application a copy of your State Permit.
4. Business Name
6. Physical Business Address
8. Street Number
9. Street Name
10. Street Type
11. Apt #
13. City
14. State
15. Zip
17. Phone Number
18. Fax
20. Business Mailing Address
22. Street Number
23. Street Name
24. Street Type
25. Apt #
27. City
28. State
29. Zip
31. Owner is a(an):

    1. Individual
    2. Firm
    3. Corporation
    4. Partnership
33. Owner's Name
34. Phone
35. Email:
37. Manager's Name
38. Phone
39. Email
41. Permit Applying For:

    1. Opening Inspection Fee (applies to all food service and grocery at time of opening) $175 one time fee
    2. Food Service (restaurants and small grocery) $350 annual fee
    3. Pool (public and semi-public) $175 annual fee
    4. Daycare $350 annual fee
    5. Mobile Vendor $175 annual fee
    6. Non-Profit/Public School No charge
    7. Alcohol Sales Permit 1/2 of State Permit Fee
43. Signed:
44. Title:
45. Date:
    Date:
47. Health Grade Cards will be furnished by Health Inspector upon passing of inspection.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

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