Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

If different from physical address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Owner Name *

First Name

Last Name

Owners Phone *

(###)

###

####

"No Tax Due" Letter is Required for All Establishments *

Submitted to Lincoln County Health Department

Not Submitted to Lincoln County Health Department

Establishment Non-For-Profit *

Yes (If "yes" - "Tax Exempt" letter is required)

No

Liquor Sold/Served *

Yes

No

Smoking Allowed *

Yes

No

The applicant attests to the accuracy of the information provided in this application. The applicant affirms they will comply with the requirements of the Lincoln County Health Food Service Sanitation Regulations as established by the Ordinance dated 3-25-2013. The applicant agrees to allow the Regulatory Authority access to the establishment as specified under Section 8-4 and any other information required by law. Permits issued by they Lincoln County Health Department are non-transferable. *

Please Provide Your eSignatur below

First Name

Last Name