E-APPLICATION AND LICENSING
Developed By CPUI
Ver 01/30/2018
Kandiyohi-Renville Community Health Board
2200 23rd 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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2019 FOOD, POOLS, AND LODGING APPLICATION

Establishment Information

( )

Applicant/Owner Information

Where should notices should be sent?:

Catering:

WATER SOURCE:

SEWER SYSTEM:

Mobile Home/Camping:

Youth Camp:

Workers Compensation Information:

Pursuant to Minnesota Statutes 176.182 & 270C.72, the following applicable information is required of each license applicant:


Establishment Definitions:

Limited Food Menu - Food service with pre-packaged food that receives heat treatment and is served in the package, continental breakfast, soft drinks, coffee, non-alcoholic beverages, and/or dishwashing (Ex. Senior dining sites.)

Small Establishment - Food service with no salad bar and equipment not exceeding one deep fat fryer, one grill, two hot holding containers, and microwaves or service of dipped ice cream/soft serve frozen desserts. Establishments which do not provide catering service and which meet "Medium Establishment" equipment criteria but have a total seating capacity of 50 or less people are "Small Establishments." Establishments that only cater and are not open regular hours are "Small Establishments."

Medium Establishment - Food service with seating over 50 and using a range, oven, steam table, salad bar, or salad preparation area, more than one deep fat fryer or grill, more than two hot holding containers, or provides catering.

Large Establishment - Food service that meets the medium establishment definition and seats more than 175 people, serves a full menu selection an average of five or more days per week or caters 500 or more meals per day.

Alcohol Service From Bar - Alcoholic mixed drinks are served or where beer or wine are served from a bar.

Lodging - A building, structure, enclosure, or any part thereof used as, maintained as, advertised as, or held out to be a place where sleeping accommodations are furnished to the public as regular roomers.

Bed and Breakfast - Owner occupied residence with five or less rooms for overnight accommodations. Serves only breakfast to guests.

Public Swimming Pool - A pool is any public pool including but not limited to a swimming pool, spa, wading pool, and zero depth pool which is not a private residential pool.

Spa Pool - A public hot water pool intended for seated recreational use.

Youth Camp - Where food and lodging are provided for ten or more minors, operated continuously for a period of five days or more each year.

(Select only one highest applicable category) Fee Paid


ALCOHOL:

OTHER: (Select all applicable categories)

x $6.00 + $160.00 Base Fee $
0

x $6.00 + $160.00 Base Fee $
0

x $75.00 $
0

x $50.00 $
0

$.00

Submit this total with application: Total Fee $
0

MAKE CHECKS PAYABLE TO: KANDIYOHI-RENVILLE COMMUNITY HEALTH BOARD

*LATE PENALTY: All license payments are due on or before December 31st . Any payment received, delivered, or postmarked on or after January 1st will be assessed a $132 penalty . Any payment received, delivered, or postmarked on or after February 1st will be assessed a $230 penalty . If no payment is received as of March 1st, the establishment will be closed.

Reduced Fee: New businesses or new owners opening after October 1st, 2019 and before December 31st, 2019 are required to pay one half (1/2) the annual fee.

License fees are nonrefundable.

Complete all applicable information or application will be returned.

For those applying for a small, medium, or large food establishment license, it is required that a copy of one full-time employee's State Food Manager Certificate is submitted along with this application.

Drop files here to upload
If form needs resubmission all files will be saved, but not shown
except in the case of session expiration

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

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