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Annual Permit Expiration Date and Permit Fee Extension Request
This form has been modified since it was saved. Please review all fields before submitting.
Current Business Information:
Date(s) of Temporary Closure:
Reopen Date (projected):
I attest that the business listed above was temporarily closed due to the COVID-19 pandemic during timeframes listed above. During the temporary closure, the permitted establishment conducted no drive-thru, delivery, food pick-up, or any activities required or allowed under the permit, or otherwise defined by the Maricopa County Environmental Health Code.
Establishments that were temporarily closed in calendar year 2020 must have met the parameters above to qualify for the extension. Any extensions for calendar year 2020 permit fees approved by the Department must be paid in full no later than December 31, 2021.
The Department may review its inspection history of the establishment in determining how to proceed with the extension of your annual permit expiration date and permit fee.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Electronic Signature of Responsible Party
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