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2. LCHD Logo
   
4. Application for Food Establishment Permit
6. I (We) hereby apply for a permit to operated a Food Establishment in Livingston County
8. Establishment Name
9. Email Address
11. Establishment Address
13. City
14. State
15. Zip Code
17. Establishment Phone Number
18. Fax Number
22. Billing Address (if different from above)
24. Owner/Company Name:
26. Address
27. City, State Zip Code
29. Phone Number
30. Fax Number
31. Email Address
35. Does the establishment do catering or have a delicatessen?

    1. Yes
    2. No
37. Does the establishment provide retail sale of food (grocery store, convenience mart, drug store, variety store, etc.?)

    1. Yes
    2. No
39. Please complete the Food Establishment Category Assessment on the next page and return application with appropriate fee to:
41. Submit Completed Form & Payment

    Once completed, please send completed document and remit payment to: 

    Livingston County Health Department
    310 E Torrance Ave
    Pontiac, Illinois 61764

45. For Office Use Only
47. Permit Number
48. Permit Expires
49. Permit Sent
Leave This Blank:


50. Print Only

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