hhs info

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Licensure and Regulatory Services
255 Rockville Pike, Ste 100
Rockville, Maryland 20850-2368
240-777-3986 Fax 240-777-3088
www.montgomerycountymd.gov/licensure

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TRANSIENT LODGING FACILITY LICENSE APPLICATION
Application is hereby made for a license to operate a Transient Lodging Facility in Montgomery County, Maryland

New  Renewal                 (Please Print)
TODAY’S DATE____________________

Name of Facility:  __________________________________________________Phone #: ________________ 
                                                                                                                                               Include Area Code

Address of Facility: ______________________________________________________________________
                                                               Street Number and Street Name

________________________________________________________________________________________  
            City                                                State                                                                               Zip Code                 

Name of Owner: _________________________________________________ Telephone #:  __________________
                                                                                                                                                         Include Area Code

Federal Tax Identification #: __________________
Fax Telephone:__________________________Email Address:_________________________________________
                           Include Area Code

Address of Owner:  ___________________________________________________________________________
                                                            Street Number and Street Name

________________________________________________________________________________________  
City                                                State                                                                               Zip Code                 

Resident Manager: _________________________________________________ Telephone #:  __________________
                                                                                                                                                         Include Area Code

Type of Facility (check one)                                                              Number of Guest

                    Hostel (Hotel, Motel, Motor Court, etc.)                ______________

                  Tourist Home                                                          ______________

                   Rooming House                                                     ______________

                   Boarding House                                                     ______________

 

Has any applicant been adjudged guilty of violating any of the following provisions of Article 27 of the Annotated Code of Maryland as amended: Sections 16 to 18 inclusive (bawdy houses and house of ill fame), Section 133 (disorderly houses), Sections 288 to 291 inclusive and Sections 296, 297, 300, 301 (gaming), Section 343 (illegal keeping of or sale of narcotics), Section 497 to 498 (opium joints), Section 128 (disturbance of the peace?

              Yes            No     If the answer to any of the above is yes, please attach an explanation to this application.

 NoteNew applicants must attach a current Use and Occupancy Permit and Fire Marshal approval.          

Payment Method: 
Fee Information:  Please refer to Transient Fact Sheet 

Check Money Order (No cash is accepted) Visa Mastercard  (No other credit cards are accepted )

Organization: _________________________________Cardholder’s Name:______________________________

Credit Card No:_________________________________ Exp. Date:______________  Amt: $_______________

I agree to pay the above total amount according to the card issuer agreement.

 Cardholder’s Signature: _______________________________________________________

Submit completed application and application fee to address at the top of the application. Checks or money orders are payable to “Montgomery County, Maryland”.
 

 

OFFICE USE ONLY

   
  Receipt Number:  ______________                  Date Issued:  _______________
  Amount Paid:  _________________   Date Expires:  ______________
  Check/Money Order Number:  ______________   Record Number:  ____________