APPLICATION FOR A HOSPITAL, NURSING HOME, REST HOME, ADULT CARE HOME OR OTHER INSTITUTION

Name of Facility:
Location Address:
City:	State:	NC	Zip:
Facility phone #:	Email:
Owner of Business:
Mailing Address:
City:	State:	Zip:
Contact Phone #:	Email:
Owner of Building:
Mailing Address:
City	State:	Zip:
Contact Phone #:	Email:

Type of Facility:	Rest Home Nursing Home Hospital Other Institution
Please specify the following:
Sewer:	Public/Municipal	On-site Wastewater System
Water:	Public/Municipal	Private Water Supply
Is the facility new construction or remodeled? Yes No
If a well is located on the property, what year was it constructed?
How many beds will be provided in this facility?
How do you plan to prepare all or most meals?
Will you be washing laundry onsite? Yes No

To assure that your application is processed in a timely manner, please submit a completed application including the following:

Zoning Permit

Site Plan showing all structures, property lines, wells, septic systems, dumpster, parking

Building floor plan drawn to scale showing all rooms including bathrooms, bedrooms, dining areas, storage areas, janitorial closets, laundry, etc.

If preparing meals on-site, also complete an application for foodhandling establishments as well.

Review and approval of these plans and specifications by the Cleveland County Health Department does not indicate compliance with any other code, law or regulation that may be required – federal, state, or local. A pre-opening inspection of the establishment with equipment and furniture in place will be necessary to determine if it complies with the local and state laws governing the sanitation of institutions.

You will be responsible for obtaining approval from appropriate zoning and building inspection departments. Their numbers are included below to assist you.

ZONING / BUILDING INSPECTION	FIRE MARSHALLS

Shelby 704-484-6805	704-484-6816

Kings Mountain 704-734-4599	704-734-0555

Cleveland County 980-484-4975/4997	980-481-4841

If your business will be located in any jurisdiction other than those listed above, please check with your city manager and/or town hall for permitting assistance.

Proposed opening date:
Date Application Submitted:
Applicant’s Signature:

APPLICATIONS CAN BE SUBMITTED IN PERSON OR BY MAILTO:

Cleveland County Permits Office

1333 Fallston Road

Shelby, NC 28150

Rev. 12/23