Fill in Your Mississippi 297 E Template
Content Overview
The Mississippi 297 E form is a crucial document for anyone seeking to operate a facility that requires a permit from the Mississippi State Department of Health. This application is designed to collect essential information about the facility, including its name, physical address, and the owner’s details. It also requires the applicant to specify the type of ownership—whether it is an association, corporation, individual, partnership, or other entity. The form emphasizes the importance of compliance with health regulations and includes a section for the applicant to acknowledge receipt of the relevant guidelines. Additionally, it outlines the responsibilities of the owner or manager in requesting an inspection and permit issuance, while also granting the Department of Health the right to conduct inspections at any time the facility is operational. The form further clarifies that permits can be suspended or revoked for just cause, ensuring that health standards are maintained. Completing the Mississippi 297 E form accurately is vital for a smooth permitting process and compliance with state health regulations.
Mississippi 297 E Preview
ApplicationforNewPermit
For Health Department Use Only
NameofFacility |
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FacilityIDNumber |
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PhysicalAddress |
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PINNumber |
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EnvironmentalistCode |
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MailingAddress (if different from physical address) |
FacilityPhoneNumber |
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PHPriority |
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FacilityManagerName |
Fax# |
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Owner is (check[✓] one): ❑ Association |
❑ Corporation |
❑ Individual |
❑ Partnership |
❑ Other ____________________ |
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OwnerName |
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Owner/Designee |
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Designee/ContactInfo |
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Address |
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PhoneNumber/Cell |
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CorporateSupervisor(if applicable) |
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Address |
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PhoneNumber |
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SmokeFree |
❑ Yes |
❑ No |
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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 |
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AddressEmail
PhoneNumber
ForHealthDepartmentUseOnly
ApplicationApprovedDate _______________________________________ |
Signature _____________________________ |
Facility is (check [✓] one): ❑ New ❑ Remodel ❑ Conversion |
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Plan ReviewApprovedDate ______________________________________ |
Signature _____________________________ |
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MississippiStateDepartmentofHealth |
Revised5/12/09 |
FormNo. 297E |
File Features
| Fact Name | Details |
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| Purpose of Form | The Mississippi 297 E form is an application for a new permit for facilities regulated by the Mississippi State Department of Health. |
| Governing Law | This form is governed by the Mississippi Code Annotated, Title 41, Chapter 3, which outlines health regulations for facilities. |
| Owner Types | Applicants must specify the type of ownership, which can be an Association, Corporation, Individual, Partnership, or Other. |
| Smoke-Free Status | The form requires applicants to indicate whether the facility is smoke-free, promoting public health standards. |
| Inspection Agreement | By signing the form, the applicant agrees to allow health department representatives to inspect the facility at any time during business hours. |
| Permit Revocation | Permits issued may be suspended or revoked for just cause, as determined by the regulatory authority. |
| Revision Date | The current version of the Mississippi 297 E form was revised on May 12, 2009, ensuring compliance with updated regulations. |
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