Owner:                                                                                       Day Phone:

Cell:                                                                                           Billing Address:

Facility Phone:

Fax:

Facility Name:

FACILITY LOCATION (911 address, include town):
..Former Name (if there was a food service business here before):
..Type of business:
         __Catering (date, location and menu will be submitted prior to a scheduled event)
         __Convenience
         __Mobile Unit; Location of primary set up planned for:
         __Restaurant (providing seating for max. of ______people.
         __Other:

HOURS OF OPERATION:            a.m. to            p.m., Days closed:

Water supply is __Private well  __Public from town of
Sewage is __Private system   __Public from town of

__Own building & land;     __Rent from:

Workmen's Compensation Insurance thru:                                               expires on:
Insurance certificate attached,(or--no workmen's comp required, Certificate of Compliance attached).

Attach current fee payable to "CAROLINE COUNTY HEALTH DEPARTMENT" to this application.

Applicant's Signature:                                                           Date:

HEALTH DEPT USE ONLY:
PR completed on ______________   ID#________________  DATE PAID:____________,  Receipt#_______________,  $________