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Business License Application

  1. 255 South Street
    Roosevelt, UT 84066
    Phone: 435-722-5001
    Fax: 435-722-5000

  2. Business License Application: $100.00
    Remit payment with cash, check debit or credit card

  3. Business Status

  4. Type of Organization

  5. Nature of Business

  6. Is the business a mobile unit and will be parked in a parking lot to conduct the business?

  7. Will the business use, store or manufacture any chemical or hazardous materials?

  8. Is the business an Eating Establishment?

  9. If yes, Uintah Basin Health Department has regulations regarding this type of business which includes an inspection of the premise. When clearance is given you will be issued a permit to conduct business. Include a copy of the permit with this application. Also, food handler’s permits will be required to handle food items.

  10. If you have license by the State of Utah, complete this section

  11. Will the business use, store or manufacture any chemical or hazardous materials?

  12. The following licenses are subject to additional requirements. More information and additional form(s) will be required.

    Check if applicable

  13. 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.

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  15. This field is not part of the form submission.