Fillable Application For License 19-20 Revised 1 1 2020 - Fillable (Brown County Information Services)

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Application For License 19-20 Revised 1 1 2020 - Fillable (Brown County Information Services)

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APPLICATION FOR LICENSE
BROWN COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT – PUBLIC HEALTH DIVISION
In accordance with Chapter 37 of the Brown County Code of Ordinances, I the undersigned do hereby apply to the Board of Health of Brown County for a license
for the year ending June 30, 2020
I hereby certify that I am familiar with the laws, ordinances, and regulations pertaining to the conditions of said establishment in the County of Brown,
and I hereby agree, if granted said license, to obey all provisions of said laws, ordinances and regulations.
PLEASE PRINT CLEARLY THE FOLLOWING INFORMATION:
ESTABLISHMENT NAME PHONE _______________________________
ESTABLISHMENT ADDRESS _____________________CITY ZIP CODE ____________
LEGAL LICENSEE ________________________________________________________________________E-MAIL ___________________________________________
PRINTED NAME OF APPLICANT: SIGNATURE OF APPLICANT: _______________
MAILING ADDRESS:_______________________________________________________________________________________________________________________
(Please indicate where correspondence should be mailed to – if NOT indicated it will be mailed to the establishment)
THIS APPLICATION MUST BE SIGNED TO OBTAIN A LICENSE – Please Refer To Back of Application For Mailing Instructions.
01 Pre-inspection
NEW = 40% of License Total (Total Fees X .40) $ ____________
EXISTING = 30% of License Total (Total Fees X .30) $ ____________
PERMANENT RESTAURANTS & ESTABLISHMENTS
02 Prepackaged food only $162
Food Prep on Site – Risk Categories
05A *Simple < $50,000 Gross sales $499
05B *Simple $50,000-$200,000 Gross sales $564
05C *Simple >$200,000 Gross sales $636
06A *Moderate < $100,000 Gross sales $682
06B *Moderate $100,000-$400,000 Gross sales $744
06C *Moderate > $400,000 Gross sales $804
07A *Complex < $150,000 Gross sales $855
07B *Complex $150,000-$600,000 Gross sales $918
07C *Complex > $600,000 Gross sales $975
10 Additional Food Prep Area (Within Establishment) $106
13 Tavern $149
13A Additional Tavern Area $ 38
Mobile Restaurant and Service Base Fees –
Operate ONLY in Brown County:
02M Pre-Pack (pre-made/pre-packaged meals from approved source) $162
05M Simple Food Prep $249
06M Moderate Food Prep $341
07M Complex Food Prep $427
State Licensed Mobile Restaurants Based in Brown County:
02S No Food Prep/No Processing at Base $162
05S Simple Food Prep at Base $249
06S Moderate Food Prep at Base $341
07S Complex Food Prep at Base $427
Retail Food – Risk Categories
14 Soft Drink Stand or Frozen Confection $149
15 Micro Market $ 40
15A Micro Market (2 or more located in same building) $ 60
16 ***Ag Code 55 $162
17 ***Ag Code 44 - Potentially Hazardous $499
17A ***Ag Code 44 - Non-Potentially Hazardous $499
18 ***Ag Code 33 $550
19 ***Ag Code 22
A. < $250,000 Gross Sales $636
B. $250,000-$600,000 Gross Sales $804
C. $600,000 - $1,000,000 Gross Sales $975
20 ***Ag Code 11
> $1,000,000 Gross Sales $1482
Mobile Retail Food Establishment and Service Base Fees –
Unit Operation ONLY in Brown County:
16M – Ag 55 Non-Processing $162
17M – Ag 44 Processing Non-Potentially/Pot. Hazardous <$25K Sales $249
18M – Ag 33 Processing Non-Potentially Hazardous ≥$25K Sales $275
19M – Ag 22 Processing Potentially Hazardous ≥$25K Sales $317
State Licensed Mobile Retail Units:
16S Service Base: Non-Processing $162
17S Service Base: Processing $249
Hotel/Motel
26 5-30 Rooms
27 31-99 Rooms
28A 100 - 199 Rooms
28B 200 + Rooms
Swimming Pools
29 Outdoor Pool
29A Additional Pool (outdoor)
30 Indoor Pool
30A Additional Pool (indoor)
31 Pool Slide, Water Slide Or Additional Water
Attraction Feature
Manufactured Homes Community
33 1-20 Sites
34 21-50 Sites
35 51-100 Sites
36A 101-175 Sites
36B 176 + Sites
Campgrounds
37 1-25 Sites
38 26-50 Sites
39 51-100 Sites
40A 101-199 Sites
40B 200 + Sites
41 Recreational/Educational Camp
Tattoo/Body Piercing
42 Tattoo
43 Body Piercing
44 Combined Tattoo & Body Piercing
Schools
48 Schools – limited service
49 Schools – prep on site
Temporary Events
50 **Temporary Restaurant
51 **Temporary R
etail Food Stand
52 T
emporary Tattoo or Body Piercing Booth
53 Special Event Campground 1-25 sites
54 Special Event Campground 26-50 sites
55 Special Event Campground 51-
100 sites
56 Special Event Campground 101-199 sites
57 Special Event Campground 200+ sites
Specials
23 Special Advisory Inspection
23A Special Organization Serving Meals
24 Bed & Breakfast
25 Tourist Rooming House
Fees
Other Permit Inspection Fee
Closure/Reopen Fee
Operating without a Valid Health Department License
Re-inspection Fee (See Reverse)
$399
$573
$712
$820
$252
$ 81
$591
$186
$131
$4
64
$510
$586
$650
$702
$2
48
$302
$349
$399
$448
$248
$248
$248
$3
76
$2
34
$536
$1
91
$191
$106
$180
$237
$294
$340
$391
$1
86
$129
$180
$242
$ 62
$
107
$150
THIS LICENSE IS NOT TRANSFERABLE
You MUST have a valid license BEFORE operating. All licenses expire on June 30th annually.
TOTAL DUE:
STAFF INITIALS:
REPLACING:
Approved:__________________
Approved Date: __________
Check #:______
Date:__________
ATCP 75.105 Department Fees.
(1)DEFINITION. In this subsection, “seating capacity” means the number of seats available for use by restaurant patrons.
(2
) R
ESTAURANT PERMIT CATEGORY ASSIGNMENT. (a
)
1
.
E
xcept with respect to a prepackaged restaurant, a temporary restaurant, or a mobile restaurant base with no food preparation
,
the department shall assign a restaurant to a permit category by evaluating the complexity of the restaurant based on the criteria
specified in Table ATCP 75.105A
2.
A
restaurant whose point value equals zero, shall be included in the simple permit category.
3. A restaurant whose point value is at least one but not greater than 4 shall be included in the moderate permit category.
4.
A
restaurant whose point value equals 5 or greater shall be included in the complex permit category.
5.
A
restaurant that has been ordered closed by a state or local health department or that has caused a foodborne outbreak withi
n
t
he previous licensing year shall be included in the complex category.
6. The operator of a restaurant may ask the department to reconsider the restaurant’s permit category within 30 days of the category assignment.
Determination of Restaurant Permit Category Complexity Factors Point(s)
FOOD HANDLING CRITERIA
POINTS
Food is not prepared until an order is placed.
0
Food items are held hot for one meal period or for a maximum of 4 hours, whichever is less.
0
Food preparation is limited to mixing together prepackaged products that do not need to be cooked further except for
aesthetic reasons (such as frozen soup concentrate with milk), or to condiment preparation (such as slicing pickles and
onions).
0
The restaurant contains a self-service salad or food bar.
1
The restaurant handles raw poultry, meat, or seafood.
1
The seating capacity of the restaurant or operation is 50 or more.
1
Food is served through a drive through window for food pickup.
1
The restaurant promotes delivery of ready-to-eat food products to customers.
1
Potentially hazardous foods are cooled, reheated, or hot or cold held for service longer than 4 hours.
1
Food is prepared in one location and then transported to be served in another location.
1
The restaurant contains or uses banquet facilities as well as main dining area.
1
Food is served that requires preparation activities such as chopping, dicing, slicing, boiling and blanching in order for
that product to be served.
1
AG CATEGORY
DESCRIPTION
11
Process potentially hazardous foods / sales of at least $1,000,000
22
Process potentially hazardous foods / sales of at least $25,000, but less than $1,000,000
33
Process non-potentially hazardous foods / sales of at least $25,000
44
Process non-potentially or potentially hazardous foods / sales of less than $25,000
55
Not engaged In processing
RE-INSPECTION FEE SCHEDULE
First follow-up visit w/o priority/critical violation corrected: $150.00
Second follow-up visit w/o priority/critical violation corrected: Additional $300.00
Third follow-up visit w/o priority/critical violation corrected: Additional $450.00 +
+ = Establishment Closure
PLEASE NOTE: If the re-inspection fee is not received within 45 days of billing
an additional $50.00 late penalty will be assessed.
In Addition: There is a $127.00 penalty fee for Not having a Certified Food Manager on Staff as required in Wisconsin Administrative
Code ATCP 75 Appendix Ch. 12-201.11. This fee is increased to $255.00 if you are still not in compliance 12 months later.
**County Code 50/51: The Brown County Health and Human Services Department – Public Health Division will honor a current state license
for an additional $62.00 inspection fee.
THIS LICENSE IS NOT TRANSFERABLE ~ A $150.00 PENALTY FEE WILL BE ADDED TO ALL ESTABLISHMENTS
OPERATING WITHOUT A VALID PUBLIC HEALTH DIVISION LICENSE.
PLEASE REMIT COMPLETED APPLICATION WITH PAYMENT TO:
Brown County Health and Human Services Department
Public Health Division - Attn: Licensing
2198 Glendale Ave
Green Bay, WI 54303
Application_For_License_19-20_Revised_1.1.2020
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Application For License 19-20 Revised 1 1 2020 - Fillable (Brown County Information Services)

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Completed 17 July 2020

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