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PUBLIC HEALTH PERMIT/LICENSE - SUPPLEMENTAL APPLICATION
SHARED FOOD FACILITY/TENANT FOOD OPERATOR
SPECIALIZED FOOD SERVICES
Environmental Health Division
5050 Commerce Drive, Baldwin Park, CA 91706-1423
www.publichealth.lacounty.gov/eh
SHARED FOOD FACILITY
Name of Shared Food Facility (SFF):
Business Start Date:
Operational Details:
☐ Retail ☐ Wholesale
IRS EIN#:
Permit Type:
☐ Quarterly ☐ Annually (July 1 to June 30)
Operation Period:
☐ Jul.-Sept. (1
st
Qtr.) ☐ Oct.-Dec. (2
nd
Qtr.) ☐ Jan.-Mar. (3
rd
Qtr.) ☐ Apr.-Jun. (4
th
Qtr.)
Assigned Space #:
Number of Food Employees:
Certified Food Protection Manager Certification Obtained (Provide proof within 60 days): ☐ Yes ☐ No
Storage Required:
☐
Cold Storage ☐ Freezer Storage
☐
Dry Food Storage
EQUIPMENT
Identify new equipment (Manufacturers’
specification sheets required) to be installed or
brought into the Shared Food Facility:
☐ N/A ☐ Other, specify: ___________________
Equipment used to transport food to service location:
☐ Holding Cabinet ☐ Insulated Transportation Equipment
☐ Other, specify: ____________________________________
APPROVAL FROM OTHER AGENCIES (if applicable)
☐
California Department of Public Health
☐ U.S. Department of Agriculture
☐ Other, specify: __________________________
☐
California Department of Food and Agriculture
☐ U.S. Food and Drug Administration
DOCUMENTS TO SUBMIT
The following documents are required in addition to the documents listed on page 2 of the Public Health/License Application:
• Copy of the signed lease agreement from the Shared Kitchen Facility
• A floor plan of the operator’s kitchen illustrating all food related equipment
• The manufacturers’ specification sheets for all food related equipment
ADDITIONAL
INFORMATION
•
The application review fee of $180 is to be paid at the time of application submission. Payments can be made by check
and payable to Los Angeles County or online once you receive the invoice.
• Retail and wholesale operators are to provide a complete menu or list of prepared food products using page 2 of this
application.
• Contact the Specialized Food Services Program at (626) 430-5421 if you have questions.
I hereby certify under penalty of perjury that the above information is true and correct and will operate in compliance with the
requirements set forth in the California Health and Safety Code. Any changes to approved operations must be reported to the
Specialized Food Services Program in writing prior to change.
Signature:
Title:
Print Name:
Date:
Date of Application:
Legal Name of Business (DBA):
X