Food 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 FOOD, POOLS, AND LODGING APPLICATION

Renewal New Owner

Establishment Information

Registered Legal or DBA Name:

Establishment Address:

City: State:

Zip:

Telephone: Days of Week Open:

Business Hours:

Seasonal ( From: To: )

Seating Capacity:

Emergency Contact #:

Applicant/Owner Information

Owner Name:

Mailing Address:

City: State:

Zip:

Telephone: Email:

Where should notices should be sent?: Owner Address Establishment Address

Workers Compensation Information:

Pursuant to Minnesota Statutes 176.182 & 270C.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:

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.

*LATE PENALTY: All license payments are due on or before December 31^st . Any payment received, delivered, or postmarked on or after January 1^st will be assessed a $160 penalty . Any payment received, delivered, or postmarked on or after February 1^st will be assessed a $275 penalty . If no payment is received as of March 1^st, the establishment will be closed.

Reduced Fee: New businesses or new owners opening after October 1^st, 2024 and before December 31^st, 2024 are required to pay one half (1/2) the annual fee.

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.

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.

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