Application For Permit To Operate Public Accommodations Form - Apache County Public Health Services District
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1Apache County Public Health Services District
Environmental Health
P.O. Box 697
St. Johns, AZ 85936
Phone (928) 337-7607
Fax (928) 337-7592
APPLICATION FOR PERMIT TO OPERATE PUBLIC ACCOMMODATIONS
ESTABLISHMENT #
THIS APPLICATION WILL NOT
TYPE:
BE PROCESSED UNLESS
COMPLETED IN FULL.
DATE OF OPENING:
NUMBER OF UNIT/SPACES:
FEES
FEES ARE NON-REFUNDABLE
**Cur
*Current Permit NOT Transferable*
ASSESSOR’S PARCEL NUMBER:
BUSINESS INFORMATION:
NAME OF BUSINESS:
BUSINESS ADDRESS:
CITY:
BUSINESS PHONE: (
)
FAX: (
)
CELL: (
)
MAILING ADDRESS:
MAILING ADDRESS
CITY:
STATE:
ZIP CODE:
OWNER INFORMATION:
NAME OF BUSINESS OWNER:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME TELEPHONE: (
)
EMAIL ADDRESS:
PROPERTY OWNER:*
CONTACT #: (
)
*If different from permit holder, require a copy of lease agreement and/or notarized letter from property owner indicating lease has been made to permit holder.
I______________________________________________, hereby certify that I am the operator or authorized agent
(owner name- print)
of the above public accommodations establishment.
Signed_______________________________________________Date___________________________________
DO NOT WRITE BELOW THIS LINE
Application approved for Permit by_____________________________________________________________Date_________________________________________
Picture Identification verified and copy attached
(check box if completed) By___________________________________________
For Official Use Only
Date Received: ______________
Cash or Check: ___________
Receipt # __________________
Check No:____________
Permit Expires:______________
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