Food Cart Form

Kandiyohi-Renville Community Health Board
2200 23^rd Street NE Suite 1080, Willmar, MN 56201
www.co.kandiyohi.mn.us — www.co.renville.mn.us
Kandiyohi County: 320.231.7800
Renville County: 320.523.2570
publichealth@co.kandiyohi.mn.us — rcph@renvillecountymn.com

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2024 MOBILE FOOD UNIT APPLICATION

Renewal New Owner

Establishment Information

Registered Legal or DBA Name:

Location (if operated at only one site):

City: State:

Zip:

Telephone:

Dates of operation: through

Mobile Food Unit-Vehicle License #:

Applicant/Owner Information

Name (individual or business):

Address or PO Box

City: State:

Zip:

Phone: Email:

Mailing address if different than above:

Mailing Address

City: State:

Zip:

Telephone: Cell Phone:

Workers Compensation Information:

Pursuant to Minnesota Statutes 176.182 & 270.72, the following applicable information is required of each license applicant:

Minnesota Tax ID Number:

Federal Tax ID Number:

Worker's Comp Policy Number:

Name of Worker's Compensation Insurance Company:

Address:

Definitions:

Food Cart - A food and beverage service establishment that is a non-motorized unit, operating no more than 21 days annually at any one place or is operated in conjunction with a permanent licensed business at the site of the permanent business by the same individual or company, and readily movable, without disassembling, for transport to another location.

Mobile Food Unit - A food and beverage service establishment that is a vehicle mounted unit, either motorized or trailered, and readily movable, without disassembling, for transport to another location. The unit can operate no more than 21 days annually at any one place unless it is operated at the site of and in conjunction with a permanent business licensed under Minnesota Statutes Chapter 157 or Chapter 28A.

Seasonal Permanent Food Stand - A food and beverage service establishment which is a permanent food service stand or building, but which operates no more than 21 days annually.

Seasonal Temporary Food Stand - A food and beverage service establishment that is a food stand which is disassembled and moved from location to location, but which operates no more than 21 days annually at any one location.

FEE SCHEDULE

MAKE CHECKS PAYABLE TO: KANDIYOHI-RENVILLE COMMUNITY HEALTH BOARD

Check the appropriate boxes:

Food Cart ………………………………………………………. $270

Mobile Food Unit ……………………………………………… $270

Seasonal Permanent Food Stand ………………………………. $270

Temporary Food Stand ……………………………………….... $270

Submit this total with application: Total Fee $

Please attach additional information as needed

1. List all food and beverages which will be served at this establishment. Please indicate food sources and place of preparation.

2. List all equipment used in this food service operation.

3. Describe facilities provided for hand washing purposes.

4. Describe facilities and procedures for dishwashing.

Complete all applicable information or application will be returned.

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If form needs resubmission all files will be saved, but not shown
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This is to certify that I am the individual who is the subject/business owner of the requested application.

This statement is to certify that all of the information in this application is true and correct and has been provided by the above named subject/business owner.

I certify that the information provided on this application is accurate and complete.

Online Application Completed

ByDate

Enter in your federal tax ID to prepopulate the form with last years values

Federal Tax ID