Placer County Grant Application for Restaurants and Bars

This application must be completed by the owner or legal representative (Responsible Agent) of the owner and owner information must match the on-file information with Placer County Environmental Health (EH). The grant funds will be distributed to the owner listed in this on-file information. These grant funds intended to be disbursed through this program are CARES federal funds and you must follow all federal funding guidelines. This award may not be sub-granted and you may not act as a pass-through or fiscal agent for the purpose of channeling funds to other parties. Receipt of other COVID-19 support funds does not preclude applicant from receiving these funds. If successful, a warrant (check) will be mailed to applicant via United States Postal Service utilizing the address chosen as the mailing address in this application and will be made payable to the entity name on the W9 form.

Facility addresses cannot be changed in this application. They are associated with the health permit for this facility. Contact (530) 745-2301 with questions.

* = Required Field

Please provide answers to all of the following:

Facility ID (FA) Number (CASE Sensitive)

Business Name

Permit Category

Primary Business Owner

Primary Business Owner Mailing Address

Please update email and phone number if necessary

Primary Contact Email

Primary Contact Phone Number

Business Physical Address

Business Mailing Address

Legal Representative (Responsible Agent) Name

Legal Representative (Responsible Agent) Physical Address

Send check to:

Primary Business Owner Address

Business Physical Address

Business Mailing Address

Legal Representative (Responsible Agent) Address

Is your business located in Placer County

Yes

No

How many employees did you have prior to COVID?

How many employees now.

As a result of COVID-19 have you experienced any of the following (select all that apply)?

A temporary closure

A reduction in your capacity

Increased costs related to safety supplies

Increased costs to comply with State guidelines

Required documents

W-9

CA590

Additional Comments

Signature

I certify that I am the owner or legal representative of the owner and that the above information is correct under penalty of perjury

Today's Date

NOTE: A copy of this application will be sent to the email address on this page after submission.

Confirm you are human

Questions: 530 745 2301

Trigger

Your session has timed out.

Click here to access the application.

EH - Restaurant Grant Application

Placer County Grant Application for Restaurants and Bars

Required documents

Additional Comments

Signature