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2. Institution Plan Review Application/ New Operator Application

4. Name of Facility
5. Phone #
7. Physical Address of Facility
8. City
9. Zip
11. Owner of Facility
12. Phone #
14. Mailing Address of Facility
15. City/ State
16. Zip
18. Applicant/ Contact Person
19. Phone #
21. Applicant Email Address
23. Relation to owner (mark one)

    1. Architect
    2. Employee

    1. Owner

    1. Contractor

    1. Other

27. Facility Information To Be Completed by Applicant

29. Type of Facility:

    1. Hospital
    2. Nursing Home

    1. Adult Day Service Facility

    1. Assisted Living

    1. Other Institution
31. Construction type:

    1. New

    1. Remodel Existing Structure

    1. Change of Ownership
33. Scope of Work
35. Sewage Disposal

    1. Municipal

    1. Septic
36. Water Supply

    1. Municipal

    1. Well
38. Proposed operating days and hours:
40. Proposed date that facility will open:
42. Number of residents/patrons presently or requesting licensing for:
44. Adult Day Service Only: Meals Provided:

    1. Breakfast

    1. Lunch

    1. Dinner

    1. Patron will bring bag lunch
46. Meal Preparation:

    1. Onsite

    1. Offsite*
48. *Offsite: Specify location:
49. How is it Transported:
51. Dining Utensil Type:

    1. Single Service

    1. Multi-use
53. Note

    A separate Food Service Application must be submitted if food is to be served within hospitals, nursing homes, assisted living, and other institutions.

57. Both Applicant and Owner/Director must sign Application

59. Applicant NAME & TITLE:
60. Date
    Date

    Date
62. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature
66. If this is a new facility being constructed:

    SUBMIT THIS APPLICATION WITH PLANS TO: CRAVEN COUNTY ENVIRONMENTAL HEALTH 2818 NEUSE BLVD. NEW BERN, NC 28562.

68. Visit:
    https://ehs.ncpublichealth.com/rules.htm

    to view all sanitation regulations

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field