Fillable REQUEST for VARIANCE PUBLIC HEALTH DEPARTMENT (Hennepin County)

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REQUEST for VARIANCE PUBLIC HEALTH DEPARTMENT (Hennepin County)

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The REQUEST for VARIANCE PUBLIC HEALTH DEPARTMENT (Hennepin County) form is 2 pages long and contains:

  • 1 signature
  • 10 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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PUBLIC HEALTH DEPARTMENT
(OVER)
REQUEST for VARIANCE
ESTABLISHMENT INFORMATION
Establishment Name: _____________________________________________________
Phone: _______________________________
Address: ______________________________________
City: ____________________
State: __MN__
Zip: ________________
Existing Establishment
Contact: __________________________________
Email: ________________________________
*NOTE: if the application is for multiple Hennepin County licensed locations, a separate list must be attached that includes each location
that is to be covered under the variance. This list must include the following: each establishment name (as it appears on the Hennepin
County License), the complete address for each establishment and the establishment owner (as it appears on the Hennepin County
License) or other contact name for each location.
VARIANCE INFORMATION
Type of Variance
(check appropriate box)
:
Facility / Construction Material
Equipment Food Code Process
Food Code Definition Specialized Process Other: _____________________
____________
Request Type:
New Renewal –
expiration date of current variance _______________________________
State the Rule(s) from which you are requesting a variance (attach additional pages if necessary). The MN
Rules can be found at https://www.revisor.mn.gov/rules/ Hennepin County Ordinances can be found at
https://www.hennepin.us/business/licenses-permits/food-beverage-lodging
State the reason(s) why the rule cannot be met (attach additional pages if necessary).
Hennepin County Public Health
1011 South First Street, Suite 215, Hopkins, MN 55343
612-543-5200
Epi-envhlth@hennepin.us
Explain in detail the alternate measures that will be taken to ensure equivalent protection (attach additional
pages, diagrams, scientific data, etc. if necessary).
This variance is not approved until the applicant has been notified in writing
I, the undersigned, agree to comply with the terms of the variance as issued by Hennepin County Public
Health Department, Environmental Health. Failure to do so may result in variance revocation or regulatory
action.
Applicant Name (Print): _____________________________________________
Title: _______________________________________
Applicant Signature: ____________________________________________________________________
Date: ___________________
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REQUEST for VARIANCE PUBLIC HEALTH DEPARTMENT (Hennepin County)

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Completed 24 December 2020

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