PUBLIC HEALTH PERMIT/LICENSE APPLICATION
Environmental Health Division
5050 Commerce Drive, Baldwin Park, CA 91706
www.publichealth.lacounty.gov/eh
(888) 700-9995
Please fill out each section completely by printing or completing fillable PDF. See page 2 for instructions, list of required
documents to be submitted with your application, and instructions for payment.
Date of Application: ________________ Select One: New Business
First Date of Operation: ______________ Change of Ownership
BUSINESS TYPE
A separate application is required for each business type.
Businesses noted with a red asterisk (*) also require a supplemental
application to be completed. These can be found on our website at http://publichealth.lacounty.gov/eh/about/permit.htm.
Animal Keeper*
Boarding Home
Body Art*
Cannabis*
Commercial Laundry*
Certified Farmers Market
Condominiums
Food Facility
Garment Manufacturing*
Hotel or Motel*
Interim Housing Facility
Laundry Self-service
Massage Establishment*
Mobile Food Facility*
Public Swimming Pool
Residential Hotel/Single Room Occupancy
Self-hauler (Municipal Solid Waste)*
Sewage Pumper Truck
aitcl*
Solid Waste Facility
heater
Toilet Rental Agency
Vending Machine
Waste Collector*
Water Systems (Public)
Wiping Rag Facility*
___________________________
BUSINESS INFORMATION
LEGAL NAME OF BUSINESS (DBA):
__________________________________________________________
Business Street Address
Unit
City
Zip
Phone
Email Address (for Reports & Communications)
Website address
Hours of
Operation:
24 Hrs.
Open: M:_________ T:_________ W:_________ Th:_________ F:_________ Sa:_________ Su:__________
Closed: M:_________ T:_________ W:_________ Th:_________ F:_________ Sa:_________ Su:__________
OWNERSHIP INFORMATION
Type: Individual/Sole Proprietorship Partnership LP LLP Corporation LLC
Name
Phone
Email
OWNER 1:
OWNER 2:
Emergency Contact:
BILLING INFORMATION
Use business address for billing Send billing to address below:
Street Address
Unit
City
State
Zip
TERMS
I HEREBY SUBMIT THIS APPLICATION FOR A PUBLIC HEALTH PERMIT/LICENSE to conduct the above-mentioned business, occupation or
other activity in accordance with the laws, ordinances, and regulations that are now or may hereafter be in force pertaining to the above-
identified facility. I certify that I am the owner or authorized representative of this business and that all statements are true to the best of my
knowledge. After issuance of the public health permit/license, I hereby consent to all necessary inspections conducted by the Department of
Public Health, Environmental Health Division.
I understand that Public Health Permits/License are not transferable and non-refundable. I understand that refunds may be considered only
when funds are collected in excess, erroneously, or as double payment. I shall notify this agency in writing if I transfer ownership, discontinue
operation or change the billing address. I understand that failure to do so may result in an obligation to pay additional penalties.
I understand that a failure to maintain a current Public Health Permit/License may result in the closure of the facility, pursuant to Los Angeles
County Code, California Health and Safety Code, and/or applicable local ordinances.
I understand that any construction, alteration or repair, including, but not limited to, equipment changes or alterations, a menu change, or
change in method of operation requires review and approval by Department of Public Health, Environmental Health Division.
Print Name: Title:
Signature: Date:
OFFICE USE ONLY
Amount
Owed:
(To be determined by Specialist on date of approval)
Payment
Due By:
SR
#:
PE Code: PE Description:
Billing
Status:
Invoice
#:
09/22
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