Application Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Licensure and Regulatory Services
255 Rockville Pike, Ste 100
Rockville, Maryland 20850-2368
240-777-3986 Fax 240-777-3088
www.montgomerycountymd.gov/licensure

EATING AND DRINKING ESTABLISHMENT /FOOD SERVICE FACILITY LICENSE APPLICATION

NOTE: LICENSES ARE NOT TRANSFERABLE FROM LOCATION TO LOCATION OR PERSON TO PERSON

New �Renewal � Change of Owner � Name Change �

TODAYS DATE: ______________

Number of Seats or Square Footage (if no seats): ___________

Mail license to: Facility � or Owner �

Name of Facility: ______________________________ Telephone No. (with area code): _______________

Address of Facility: ___________________________________________________________________

(include street number, suite number, street name, city, state, and zip code)
Fax No: ___________ Email: _____________________ Does the Facility Provide Catering? Yes � No �

Owner/Corporation Name: _________________________ Telephone No. (with area code): _____________

Address of Owner/Corporation: ___________________________________________________________

(include street number, suite number, street name, city, state, and zip code)

Federal Tax Identification No.: ________________ Former Name of Facility (if applicable): ________________

Working Hours and Days Open for Business: ________________________________

Water Supply: Public � On-Site/Well � Sewage: Public � On-Site/Septic System �
(NOTE: Allow 30 days for well water testing and septic inspection. Contact DPS/Well & Septic Section at 240-777-6160)

WSSC � or City of Rockville / Poolesville � Account Number: __________________________________________

Workers Compensation Insurance Company Name: ________________ Policy/Binder No.: ___________
Check here � if this facility is operated by a sole proprietor with no employees, or by members of a partnership or LLC,
and a Certificate of Compliance has been obtained.

If you do not have Workers Compensation Insurance, you must submit a copy of the Certificate of Compliance issued by
the Workers Compensation Commission (410-864-5100 or 800-492-0479).

EMERGENCY CONTACT INFORMATION

Emergency Contact Name: ____________________________________________

Telephone Number: ______________ (NOT the facility telephone number)

Fax Number: ______________ Email: ______________
Montgomery County Department of Health and Human Services must be notified when the emergency contact information changes

I hereby certify that the above information is accurate and complete: Signature of Owner or Agent: ___________________________________________________________ Printed Name and Title of Above Signatory: ___________________________________________________ Payment Method: Cash is not accepted. Checks or Money Orders made payable to Montgomery County, MD Check � Money Order � Visa � MasterCard � ________ CVV/CVC (3 digit security code) Submit completed application and fee to DHHS/Licensure & Regulatory Services.

Credit Card payment: Fax to 240-777-4531(confidential fax line)

Cardholders Name: _____________________ Cardholders Signature: ____________________________

Credit Card No: _________________________________ Exp. Date: ____________________

Amount: _____________ I agree to pay the indicated total amount according to card issuer agreement.

OFFICE USE ONLY: Receipt No: _______________ Amount Paid: ________ Date Issued: _____________

Check No: ________________ Expires: ________ Staff Initials: _____________

Updated on 5/10

FEE SCHEDULE

Type of License Fee

(A) Itinerant, Carryout, Restaurant with 25 seats or less, or a Market with 3000 sq. ft. or
less of floor area:

$365.00

(B) Restaurant with 26 to 75 seats or a Market with 3001 sq. ft. to 10,000 sq. ft. of floor
area:

$405.00

$440.00

(D) Non-Profit Charitable Organization:

$100.00

(E) Facilities other than Non-Profit Charitable Organizations that are also licensed as
Hospitals, Care Homes, or Private Schools:

$115.00

(F) Mobile Facilities, Event Series, or Seasonal or Pool Snack Bars operating for more
than 14 days but less than 90 days with operating dates printed on the license:

$175.00

(G) Commercially Prepackaged, Non-Hazardous Food incidental to a non-food business:

$130.00