Spreadsheet: 05acf047-c661-42fd-a4a7-615eff42aaeb
Sheet: Sheet1

Unnamed: 0 | Change of Ownership Form / Data Entry Form | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | Unnamed: 28 | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | Unnamed: 38 | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42 | Unnamed: 43 | Unnamed: 44 | Unnamed: 45 | Unnamed: 46 | Unnamed: 47 | Unnamed: 48 | Unnamed: 49 | Unnamed: 50 | Unnamed: 51 | Unnamed: 52 | Unnamed: 53 | Unnamed: 54 | Unnamed: 55 | Unnamed: 56 | Unnamed: 57
 |  |  |  |  |  |  |  |  |  |  |  | First Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Middle Initial |  |  |  |  |  |  |  |  | Last Name
 | Owner's home - > |  |  |  |  |  |  |  |  |  |  | Address
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | Phone No: |  |  |  |  | (                   ) |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | Extension:
 | Owner's Mailing Address |  |  |  |  |  |  |  |  |  |  | Street or PO Box No
 |  |  |  |  |  |  |  |  |  |  |  | Attn:
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]____________________________________ Fax (__________) __________-___________________
 |  |  |  |  |  |  |  |  |  |  |  | Have you had any Facility permited by Merced County Environmental Health before? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | YES |  |  |  |  |  | NO
 |  |  |  |  |  |  |  |  |  |  |  | First Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Middle Initial |  |  |  |  |  |  |  |  | Last Name
 | Secondary Owner - > |  |  |  |  |  |  |  |  |  |  | Address
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | Phone No: |  |  |  |  | (                   ) |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | Extension:
 | Mailing Address |  |  |  |  |  |  |  |  |  |  | Street or PO Box No
 |  |  |  |  |  |  |  |  |  |  |  | Attn:
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]____________________________________ Fax (__________) __________-___________________
 | Send Mail To: |  |  |  |  |  |  |  |  |  |  | Owner's Address |  |  |  |  |  |  |  |  |  |  |  |  | Facility Address |  |  |  |  |  |  |  |  |  |  | Other Address |  |  |  |  |  |  |  |  |  | (see next line)
 |  |  |  |  |  |  |  |  |  |  |  | Address |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  | St |  |  |  |  | Zip
 |  | FACILTY INFORMATION
 | Facility Name - > |  |  |  |  |  |  |  |  |  |  |  | Old Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Office Use: |  |  |  |  | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  |  | New Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Office Use: |  |  |  |  | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  | Address
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | Phone No: |  |  |  |  | (                   ) |  |  |  |  | ) |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | Extension:
 |  |  |  | Mailing Address |  |  |  |  |  |  |  | Address
 |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | State |  |  |  |  |  |  |  |  |  |  |  |  | Zip Code
 |  |  |  |  |  |  |  |  |  |  |  | Attention To:
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]_____________________________________________________________________________________________
 | Contact Persons - > |  |  |  |  |  |  |  |  |  |  | Primary Contact |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Secondary Contact
 |  |  |  |  |  |  |  |  |  |  |  |  | Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Name
 |  |  |  |  |  |  |  |  |  |  |  |  | Title |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Title
 | Day |  |  |  |  |  |  |  |  |  |  | Phone No | Phone No |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext |  |  |  |  |  | Phone No |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext
 | Night |  |  |  |  |  |  |  |  |  |  |  | Phone No |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext |  |  |  |  |  | Phone No |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext
 |  | For Office Use Only
 | Prior to opening complete the following checked items:
 |  |  | Provide proof of ownership
 |  |  | Obtain City/County approval to open
 |  |  | Obtain other agency clearance prior to opening (ie: Business License, Building, Fire, Planning)
 |  |  | Bring this form to Environmental Health
 |  |  | Obtain food safety certification within 60 days; maintain original certificate on-site
 |  |  | Fill all soap, towel and tissue dispensers
 |  |  | Clean facility
 |  |  | HCD Sticker - Contact [NAME] at (559) 283-9500 or (916) 255-2501
 |  | Annual |  |  |  |  | Permit
 |  |  | 90 day interim   valid from: __________________________________valid to:________________________________
 |  |  | Mail invoice: |  |  |  |  |  |  |  |  |  | YES |  |  |  |  |  |  | NO
 |  |  | PE(s) for this facility: |  |  |  |  |  |  |  |  |  |  | _____ |  |  | _________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Number of hours to invoice ____________________
 |  |  | ___________________________________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PE 3209
 | Owner's Signature |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | E.H. Specialist Signature                                           Date
 | O:\Programs\Food\Forms and FBI Forms\Data Input Sheet FOR CHANGE OF OWNERSHIP 092110.xls