BARRON COUNTY DHHS PERMIT APPLICATION

Transcription

1 BARRON COUNTY DHHS PERMIT APPLICATION Completion of this form is voluntary, however to receive a permit you must complete the form. To obtain a permit submit the completed application and fee(s), check or money order, payable to: Barron County DHHS. A pre-inspection is required before a permit can be issued. Incomplete information may delay processing your application. For complete mailing address, see reverse side of this form. Type or Print. Application is for: New Establishment- New construction, building change of use * Change in Ownership- Current existing business with new owner * Establishment Name Establishment Street Address, City, State and Zip Code Legal Licensee (such as name of sole proprietor or partnership, or LLC, LLP, Inc.) Licensee Street Address, City, State and Zip Code Name of Agent for the Corporation / Operator (if applicable) County Establishment Telephone ( ) address Legal Licensee Telephone ( ) Intended Date of Opening for Business Name of Former Business Name of Former Operator ID No. Chapter (3)(d), (1)(c) and 97.67(4) Stats. The department may not issue or renew a retail food establishment, hotel, campground, pool or bed and breakfast license unless the license applicant pays all fees which are due. Chapter (2)(a) (1)(a), and 97.67(1), Stats. No person may operate a retail food establishment hotel, campground, pool or bed and breakfast without a valid license issued by the department or an agent city or county. Chapter 97.30(2)(a), (1)(a) and 97.67(4) Stats. Permits released April 1 and after expire June 30 of the following year Chapter 97.41(4)(a) Stats. The local health department may establish separate fees for pre licensing inspections of new establishments, for pre licensing inspections of existing establishments for which a person intends to be the new operator or for the issuance of duplicate licenses. Within 30 days after receiving a complete application for a permit, the department shall either approve the application and issue a permit or deny the application. If the application for a permit is denied, the department shall give the applicant reasons, in writing, for the denial. A permit shall not be issued to an operator without prior inspection. Mail completed application and fees to: Barron County Department of Health and Human Services Public Health Office 335 E Monroe Ave Room 338 Barron WI Phone: Fax: TOTAL AMOUNT ENCLOSED: Your signature below will acknowledge that you have received a copy of the code or information as to where to obtain a copy and will comply with all applicable Wisconsin Administrative Code(s). SIGNATURE Applicant Date Signed 1

2 FOOD SERVICE Prepackaged off-premise $ Permit fee + $ Pre-inspection fee= $ Full-service Simple** $ Permit fee + $ Pre-inspection fee= $ Full-service Moderate** $ Permit fee + $ Pre-inspection fee= $ Full-service Complex** $ Permit fee + $ Pre-inspection fee= $1, Additional Food Prep Area $ (within establishment) Prepackaged off-premise Full-service Simple** Full-service Moderate** Full-service Complex** Additional Food Prep Area (within establishment) $ Permit fee + $97.50 Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $1, $ **Full-service categories: Total Points 0 = Simple; Total Points 1-4 = Moderate; Total Points 5 or greater = Complex Circle all that apply: Self-service salad or food bar 1 Potentially hazardous foods cooled or reheated 1 Contain or use banquet facilities 1 Food prepared one location transported to another for service 1 Handle raw poultry, meat or seafood 1 Seating capacity is 50 or more 1 Food served through drive-up window 1 Delivery of ready-to-eat foods to customers > 25% of food sales 1 Food prep includes chopping, dicing, slicing, boiling, cooling, blanching or reheating in order to serve 1 Within previous license year restaurant ordered closed by state or local health dept. or caused a foodborne outbreak 5 Certified Food Manager s Name and ID No.: Expiration Date: 2

3 LODGING Hotel/Motel/Resort (5-30 rooms) Hotel/Motel/Resort (31-99 rooms) Hotel/Motel/Resort ( rooms) Hotel/Motel/Resort (200+ rooms) Bed & Breakfast (8 or less rooms) Tourist Rooming House (1-4 rooms) Cabin, Cottages, etc. # of rooms $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ Hotel/Motel/Resort (5-30 rooms) Hotel/Motel/Resort (31-99 rooms) Hotel/Motel/Resort ( rooms) Hotel/Motel/Resort (200+ rooms) Bed & Breakfast (8 or less rooms) Tourist Rooming House (1-4 rooms) Cabin, Cottages, etc. # of rooms $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ Hotel/Motel operator, please advise us as to which you want to be classified as: Hotel Motel If a lodging facility, do you have food service for tourists, transients or guests on your premises? Yes No 3

4 CAMPGROUND Campground (1-25 sites) Campground (26-50 sites) Campground ( sites) Campground ( sites) Campground (200+ sites) FEES $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ Permit fee + $ Pre-inspection Fee= $ Number of sites Campground (1-25 sites) Campground (26-50 sites) Campground ( sites) Campground ( sites) Campground (200+ sites) FEES $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ $ Permit fee + $ Pre-inspection Fee= $ Number of sites If a campground facility, do you have food service for patrons? Yes No Layout and plan must be submitted with application for new and remodeled camps. RECREATIONAL & EDUCATIONAL CAMP $ Permit fee Pre-inspection Fee=$ Total Capacity of Camp (in number of persons accommodated at one time) $ Permit fee Pre-inspection Fee= $ Total Capacity of Camp (in number of persons accommodated at one time) 4

5 SWIMMING POOL (Per Pool) $ Permit fee + $ Pre-inspection fee= $ per pool $ Permit fee + $ Pre-inspection fee= $ per pool WATER ATTRACTION $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee= $ WATER ATTRACTION-w/up to 2 pool slides/water slides per basin $ Permit fee + $ Pre-inspection fee= $ $ Permit fee + $ Pre-inspection fee=$ Activity Cold Soak (below 72 o F) Combination Leisure River Plunge Splash Pad Swimming Therapy Vanishing Edge Vortex Wading Interactive Play Attraction Waterslide/pool slide Wave Whirlpool Zero-depth entry *Department of Commerce plan approval required for new/altered/modified pools or water attractions. Type of pool or water attraction (indicate the number of each separate type on property in check box) 5

6 TATTOO & BODY-PIERCING ESTABLISHMENTS Tattoo Establishments $ Permit fee + $ Pre-inspection fee= $ Body-Piercing Establishments $ Permit fee + $ Pre-inspection fee= $ Combined Tattoo / Body-Piercing Establishments $ Permit fee + $ Pre-inspection fee= $ Temporary Tattoo Establishments $ Temporary Body-Piercing Establishments $ Combined Temporary Tattoo / Body-Piercing Establishments $ Tattoo Establishments $ Permit fee + $ Pre-inspection fee= $ Body-Piercing Establishments $ Permit fee + $ Pre-inspection fee= $ Combined Tattoo / Body-Piercing Establishments $ Permit fee + $ Pre-inspection fee= $ Temporary Tattoo Establishments $ Temporary Body-Piercing Establishments $ Combined Temporary Tattoo / Body-Piercing Establishments $ Temporary permits are valid no more than 7 days per event. State of Wisconsin Tattooist / Body-Piercer ID No.: Expiration Date: Check the appropriate box when your business is in operation. Year Round Winter Summer 6