Schedule
FORM 1
(Regulation 4(1))
TO: THE SAINT LUCIA PUBLIC HEALTH BOARD
| Application for a licence to operate a |
| (Type of business) |
| I/We |
| (Name of business or firm) |
| of |
| (Address) |
| hereby make an application for a licence |
| (Type of licence) |
| in respect of premises situated at |
| (Address of proposed premises) |
| Signature of Applicant: |
| |
| Date: |
(Inserted by S.I. 59/2020)
FORM 2
(Regulation 4(4))
BAKERY INSPECTION REPORT
ENVIRONMENTAL HEALTH DIVISION
SAINT LUCIA
(Inserted by S.I. 59/2020)
FORM 3
(Regulation 6)
LICENCE TO OPERATE
| 20 |
| THIS IS TO CERTIFY THAT |
| of is licensed in accordance |
| with the Public Health Act and is given permission to operate a |
| until December 31st |
| This Licence is issued with the understanding that the operator adheres to the Public Health Act failing which the Licence may be revoked by the Public Health Board. |
| |
| Chairperson Public Health Board |
| N.B. Licence must be conspicuously displayed on the premises. |
(Inserted by S.I. 59/2020)
FORM 4
(Regulation 11(4))
CERTIFICATE OF HEALTH
| Name of Holder | |
| Address of Holder |
| Trade or Business |
| Date Issued |
| REMARKS |
| |
| |
| |
| |
| RENEWAL (back) |
| RENEWED TO DATE | MEDICAL OFFICER OF HEALTH | | RENEWED TO DATE | MEDICAL OFFICER OF HEALTH |
| | | | |
(Inserted by S.I. 59/2020)