The Mississippi 297 E form is an application used to request a new permit from the Mississippi State Department of Health for operating a facility. This form collects essential information about the facility, including its physical and mailing addresses, contact details, and ownership structure. Completing this form accurately is crucial for compliance and to ensure that your facility meets health and safety regulations.
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The Mississippi 297 E form serves as a crucial document for individuals and entities seeking to obtain a new permit from the Mississippi State Department of Health. This application is designed for various types of facilities, including associations, corporations, individuals, and partnerships. It collects essential information such as the facility's name, physical address, and contact details, ensuring that the Department can effectively manage and inspect the premises. The form requires applicants to indicate whether the facility is new, a remodel, or a conversion, allowing for appropriate regulatory oversight. Additionally, it includes a declaration of compliance with health regulations, underscoring the applicant's commitment to meeting state standards. By signing the application, the owner or manager grants permission for health department representatives to conduct inspections, reinforcing the importance of public health and safety. Ultimately, this form not only initiates the permitting process but also establishes a framework for ongoing compliance and accountability within the health sector.
Filling out the Mississippi 297 E form requires careful attention to detail. One common mistake is failing to provide the correct facility name. This can lead to confusion and delays in processing the application. Ensure that the name of the facility matches exactly what is registered with the appropriate authorities.
Another frequent error involves the omission or inaccuracy of the facility address. The physical address, including the city, state, and zip code, must be clearly stated. Any discrepancies can result in complications, especially if inspections are needed.
Many applicants also overlook the owner designation section. It is crucial to accurately check the appropriate box indicating whether the owner is an association, corporation, individual, partnership, or other. Incorrect selections can lead to processing delays or rejections.
Providing incomplete contact information is a mistake that can hinder communication. The form requires the owner's name, phone number, and email address. Missing or incorrect contact details can cause significant delays in the review process.
Additionally, failing to acknowledge the smoke-free status of the facility is another common oversight. Applicants must check the appropriate box to indicate whether the facility is smoke-free. This information is vital for compliance with health regulations.
Finally, the signature and date section is sometimes neglected. The applicant must sign and date the form to confirm that all information is accurate and that they understand the requirements. Incomplete signatures can result in the application being deemed invalid.
ApplicationforNewPermit
For Health Department Use Only
NameofFacility
FacilityIDNumber
PhysicalAddress
PINNumber
EnvironmentalistCode
City
State
Zip
MailingAddress (if different from physical address)
FacilityPhoneNumber
PHPriority
FacilityManagerName
Email
Fax#
Owner is (check[✓] one): ❑ Association
❑ Corporation
❑ Individual
❑ Partnership
❑ Other ____________________
OwnerName
Owner/Designee
Designee/ContactInfo
Address
PhoneNumber/Cell
CorporateSupervisor(if applicable)
PhoneNumber
SmokeFree
❑ Yes
❑ No
Ihavereceivedacopy oftheMississippi StateDepartment of Health ______________________ andam familiarwith all
applicablesections. Ihavecompliedwith all requirements of this regulation. As owner/manageroftheabovefacility, I hereby request theMississippi StateDepartment ofHealth to makean inspection andto issueapermit to operatethe facility/business namedaboveandagreethat upon proper
identification arepresentativeoftheDepartment ofHealth may enterupon thesepremises andinto this facility/business forthepurposeofmaking official inspections and/orcollecting samples ifapplicableat any timethis facility/business is open forbusiness. It is furtherunderstoodthat, shouldapermit be issued, it may besuspendedorrevokedat any timeforjust cause, as determinedby theregulatory authority.
Applicant Name/Signature
Date
AddressEmail
ForHealthDepartmentUseOnly
ApplicationApprovedDate _______________________________________
Signature _____________________________
Facility is (check [✓] one): ❑ New ❑ Remodel ❑ Conversion
Plan ReviewApprovedDate ______________________________________
MississippiStateDepartmentofHealth
Revised5/12/09
FormNo. 297E
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