Forms

Environmental Health Forms

Food Permit Applications

**NEW ONLINE FOOD PERMIT APPLICATIONS**

1.  FIRST, online payment must be made on this website by clicking on the green Allpaid button above.  Payments by check will also be accepted, make checks payable to:  Clinton County Health Department.  Write your “Establishment Name” on the check memo line.  Mail check to:  Clinton County Health Department, 930 A Fairfax St., Carlyle, IL  62231.
2.  SECOND, click on (RENEWAL) application listed below to link you to myhealthdepartment.com.  Then, create an account or login to renew your food permit application online.  Myhealthdepartment.com doesn’t have the option to print an application.
3.  THIRD, new food permits will be emailed, look for an email from HealthSpace Cloud Print in your inbox or spam/junk folder.  Permit holders must print and post their food permit in a location in the food establishment that is visible to the public.

• Application for Permit to Operate a Food Establishment
• (RENEWAL) Application for Permit to Operate a Food Establishment:  Renewal opens online April 1 through May 30, see instructions 1-3 above.
• Application for Food Establishment Construction Plan Review
• Application for Permit to Operate a Temporary Food Establishment (2-14 day event or celebration)
  *Single day events and celebrations are not required to obtain a Temporary Food Permit.  Instead, food safety education materials and guidelines from the Health Department should be obtained and followed.

• Illinois Temporary Food Stand Food Safety Guidelines
• Sanitary Guidelines for Temporary Food Establishments

Cottage Food Operations

Cottage Food Operators are required to register annually with the Clinton County Health Department before selling food products to the public. Cottage Food Operators must follow regulations outlined in the Illinois Food Handling Regulation Enforcement Act.

• Application for Cottage Food Operations Registration
  • Cottage Food Home Self-Certification Checklist
• Food Safety Plan for Acidified and Fermented Foods
• Hazard Analysis Chart
• Sample Hazard Analysis Chart
• Illinois Extension, Cottage Food Information Sheet

Sewage Forms

• Private Sewage Disposal System Information Packet:
  • Instructions for obtaining a Private Sewage Disposal System Construction Permit
  • Private Sewage Disposal System Application
  • EPA, NPDES General Permit Information and Release Form
  • Septic System Do’s and Don’ts
  • Maintenance of Aeration Units
  • List of Licensed Private Sewage Installation Contractors
  • List of Septic Tank Manufacturers and Aeration Unit Dealers
  • List of Licensed Private Sewage Pumpers
  • List of Certified Professional Soil Classifiers

• Variance Request Form
• Application for Approval of an Existing Private Sewage Disposal System
• Private Sewage Installers and Pumpers Registration Form
• Septic Tank Manufacturers and Aeration Unit Dealers Registration Form

Water Supply Forms

• Instructions for Obtaining a Water Well Permit
• Application for Permit to Construct, Modify or Abandon a Water Well
• Application for Permit to Construct, Modify or Seal a Closed Loop Well System
• Application to Seal an Abandoned Water Well by a Property Owner

Complaint Forms

• Nuisance Complaint Form
• Food Complaint Form

Other Forms

Medical Reserve Corp

• MRC Volunteer Application

Maternal and Child Health Forms

• DHS Self-Employment Record
• Employment and Income Verification form