Healthcare Health Permit Application

HEALTHCARE HEALTH PERMIT APPLICATION

Applicant Name:   Title/Position:

APPLICANT CONTACT INFORMATION

FACILITY INFORMATION

Facility Phone:   Facility Email:

Proposed Effective Date of Permit:   Existing Facility License/Permit Number (if any):

OWNERSHIP / OPERATOR INFORMATION

SERVICES, STAFFING, AND LICENSURE

Number of Licensed Practitioners:   Number of Nurses:   Support Staff Count:

INFECTION CONTROL, WASTE, AND SAFETY

Water Supply: Public   Private/Well

On-site Sterilization Equipment Present: Yes   No

ATTACHMENTS / CHECKLIST

FEES

Permit Application Fee Amount: $   Payment Method Preferred:

DECLARATIONS AND CERTIFICATIONS

By signing below, Applicant certifies under penalty of law that all information provided in this application and in any attachments is true, correct and complete to the best of Applicant's knowledge. Applicant understands that submission of false or misleading information may result in denial, suspension, or revocation of the permit and may subject Applicant to civil or criminal penalties.

Applicant hereby grants the health authority and its authorized representatives the right to inspect the facility and records during reasonable hours for the purpose of verifying compliance with applicable public health, safety, and sanitation laws, rules and regulations. Applicant further acknowledges that issuance of a permit does not relieve Applicant of any statutory or regulatory obligations and that permits may be conditioned, suspended or revoked for failure to comply with such obligations.

Applicant acknowledges that permit fees are non-refundable unless expressly provided in writing by the health authority. Applicant agrees to notify the health authority in writing within 30 days of any change in ownership, location, or material change to operations that could affect permit status.

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