Forms & Applications

All applications and forms are to be turned in to your local health department. Contact your local health department with questions regarding these applications and forms. The Chickahominy Health District accepts cash, checks and VISA for fees associated with applications.

Food Service Applications, Forms, & Regulations
Name: Description:
Food Establishment Application Application for a Virginia Department of Health Food Establishment Permit
Foodservice Plan Review Plans to review for approval before food establishment permit
FDA Food Establishment Plan Review Guide Food and Drug Administration’s guide to assist food establishments in foodservice plan reviews.
Temporary Food Establishment Application

Event Coordinator Application

*These forms can be emailed to Chickahominy.EHSS@vdh.virginia.gov if $40 fee has been previously paid within the past calendar year.

Application for a temporary food establishment. Temporary event applications must be submitted 10 business days prior to an event
State Permit Applications and regulations on food, summer camps, campgrounds, swimming pools, and migrant labor camps Link to permit applications for food, summer camps, campgrounds, swimming pools, and migrant labor camps.
FDA Federal Food Code Document Food and Drug Administration’s guide to ensure food and public health safety from food establishments
Chickahominy Health District Complaint Information Form
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Complaint information form for water, sewage, restaurants, methamphetamine, wells, foodborne illnesses, etc.
Mobile Food Unit Application Application for a Department of Health Mobile Food Unit Permit

 

Onsite Service Applications, Forms, & Regulations
Name: Description:
Chickahominy Health District Septic System Repair History Questionnaire and Instructions
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Septic system repair instructions and repair history questionnaire
Chickahominy Health District Request for Onsite Information Application to request information on wells, septic systems, or drainfields
Chickahominy Health District Complaint Information Form
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Complaint information form for water, sewage, restaurants, methamphetamine, wells, foodborne illnesses, etc.
Chickahominy Freedom of Information Request Form Form to request documents or other information under the Freedom of Information Act
VDH Septic System & Well Construction Permit Application Application for construction permit for wells or septic systems

 

Other Applications, Forms, & Regulations
Name: Description:
Hotel/Tourist Establishment Application Application for a Department of Health Tourist Establishment/Campground/Summer Camp Permit
Summer Camp & Campground Application Application for a Department of Health Tourist Establishment/Campground/Summer Camp Permit

 

Epidemiology Forms
Name: Description:
EPI 1 Form PDF Form to report disease cases to your local health department.