Minor Operations Retail Food Establishment Application

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Download "Minor Operations Retail Food Establishment Application"

Joleen Montgomery
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1 Minor Operations Retail Food Establishment Application At times, the comprehensive Retail Plan Review and Application packet doesn t fit the operations of a potential retail food establishment because the scope of the business is minor. Examples of this type of business include ice cream freezers, meat freezers, and mobile sales of prepackaged food from a commissary. To that end, the Weld County Department of Public Health and Environment (Department) has developed a simplified packet. In all cases, please call our office for consultation as to whether or not it is suitable to utilize the abbreviated paperwork. Complete and return the application to the Department at least thirty (30) days prior to the beginning of intended operation. $ Plan Review Application Fee Completed Applicable Section Owner Information Form License Application Photocopy of the Colorado State Sales Tax License (obtained from Department of Revenue*) Affidavit- Restrictions on Public Benefits (if applicable) Within fourteen (14) working days of the receipt of the above information, you will receive a response from our office advising of approval or disapproval of the submitted plans. Either plans will be approved OR changes will be required to comply with the Colorado Retail Food Establishment Rules and Regulations. Please ensure an is provided on the information form, for correspondence. A pre-opening inspection is required prior to operation. Please call to schedule the pre-opening inspection at least five (5) working days before you are ready for the inspection. Final review and license fees will be collected during the pre-opening inspection. The fees include a $50.00 per hour charge for review and inspection activities (e.g. evaluation of plan review, walk-through and preopening inspections, etc.) and a Retail Food Establishment license fee (fee varies depending upon license type and facility size). *Department of Revenue: (303) (Denver) (970) (Fort Collins)

2 Prepackaged potentially hazardous foods (burritos, salads, kraut burgers, ice cream, etc.) This type of operation is generally licensed as a prepackaged mobile unit. 1) Provide a menu or list of items that will be sold (flavors/types). 2) Where will the product be prepared? 3) At what time will they be prepared? What time is the food packaged? 4) How will a safe temperature be maintained while food is being sold? a. Can the unit holding maintain a temperature of 135 degrees or above? 41 degrees and below? b. If the unit cannot hold temperatures above 135 degrees or below 41 degrees (example: standard hard sided cooler) then time as a public health control may be used (please request form from the Department). 5) How will food items be packaged (wrapped in foil, wrapped in paper, placed in single service cups, etc.)? Note: if this operation is not an add on to a currently licensed retail food establishment, then a full plan review packet is required. Freezer Meats/ Ice Cream Freezer This type of operation is generally licensed as a grocery store 0-15,000 sqft. 1) Provide a menu or list of items that will be sold. 2) Provide the make and model number of the freezer. Note: The freezer must have a commercial certification; it cannot be a household model. 3) If applicable provide a floor plan of the building where the freezer will be located. Note: If the freezer is located at a residence, it must be in a separate location such as a garage or shed and a separate entrance must be provided so that our inspectors do not access your living area. 4) Where will food be obtained (supplier)? 5) Where will food product be sold at (days, times, locations)? 6) How will food product be held frozen if sold at another location from where stored? Note: Food products must be obtained from an approved source and be labeled with all labeling requirements (at minimum: ingredients, net weight, product name and contact information). 2

RETAIL FOOD ESTABLISHMENT INFORMATION FORM OWNER INFORMATION 1. Owner(s) Name 2. Corporation Name (as it appears on Sales Tax License) 3. Owner Address City State Zip 4. Home Phone No.

3 RETAIL FOOD ESTABLISHMENT INFORMATION FORM OWNER INFORMATION 1. Owner(s) Name 2. Corporation Name (as it appears on Sales Tax License) 3. Owner Address City State Zip 4. Home Phone No. ( ) Work Phone No. ( ) 5. Owner Mailing Address City State Zip 6. Address ESTABLISHMENT INFORMATION FOR OFFICE USE ONLY IN# ACCT. I.D. # SR# 1. Establishment Name 2. Site Address City State Zip 3. Mailing Address City State Zip 4. Phone Number: ( ) Manager/Contact Person 5. State Sales Tax Number: Seating Capacity 6. Hours of Operation: Days Su M T W Th F Sa Business Hours to / to (circle all that apply) 7. SEND LICENSE/RENEWALS TO: (check one) Owner Mailing Address Establishment Site Address Establishment Mailing Address Or: 3

4 For Agency Use Only September 1, August 31, 2018 Incomplete applications, or applications without payment (if required), will not be processed. Ownership type: Individual (must complete affidavit of residency) Corporation (LLC, LLP, S-Corp, etc.) Non-profit (includes government) Other Full legal name of owner, corporation, or non-profit: Trade name (DBA): Contact name (on site): CO Sales Tax Acct. No. Physical address of business: City: State: Zip: County where business is located: Phone number: Other contact number (mobile, fax, etc.): Mailing address (if different from above): City: State: Zip: Date you started the business: Seasonal? Mark each month you operate: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC In consideration thereof, I do hereby certify that I have complied with all items of sanitation as listed in the Colorado Retail Food Establishment Rules and Regulations (6 CCR ), and that I have complied with all orders given me by authorized inspectors of the Colorado Department of Public Health & Environment, or local board of health. I also agree that in the event sanitation items are not complied with, I will discontinue serving food until such time as requirements are met. Signature: Title: Date: Calendar Year: Check the appropriate license type from the list below. This is your license fee. License Type Code Fee No fee license (K-12 schools, non-profits) 1000 $0.00 Limited food service (convenience, other) 2000 $ Restaurant (0 100 seats) 3000 $ Restaurant ( seats) 3100 $ Restaurant (> 200 seats) 3200 $ Grocery store (0 15,000 sq.ft.) 4000 $ Grocery store (> 15,000 sq.ft.) 4150 $ Grocery store w/ deli (0 15,000 sq.ft.) 5000 $ Grocery store w/ deli (> 15,000 sq.ft.) 5150 $ Mobile unit (prepackaged) 6200 $ Mobile unit (full food service) 6300 $ Oil & Gas Temporary 7000 $ Special Event 8000 Set locally Total Due: $

5 All licenses, certifications, and registrations issued to individual owners or sole proprietors by the Weld County Department of Public Health and Environment must be accompanied by verification of citizenship. This requirement does not apply to you if you are not an individual owner or sole proprietor. Verification includes completing the affidavit and providing a notarized copy of an approved identification. Approved identification includes: A valid Colorado driver s license or a Colorado identification card; A United States military card or a military dependent s identification card; A United States Coast Guard Merchant Mariner card; A Native American Tribal Document, In addition to the above listed forms of identification, the following will be allowed. A certificate verifying naturalized status issued by an authorized agency of the United States bearing applicant s intact photograph impressed with the raised embossed seal of the issuing agency; A certificate verifying United States citizenship issued by an authorized agency of the United States bearing applicant s intact photograph impressed with the raised embossed seal of the issuing agency, or; Other approved State s driver s license or identification card. Not all states verify lawful presence prior to issuing license. Therefore, only those States listed below are deemed acceptable. 1 1 Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Virginia, West Virginia, and Wyoming; AFFIDAVIT - RESTRICTIONS ON PUBLIC BENEFITS I,, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date Firm s Legal Name: Firm s Site Address: Street Unit City Zip 4

6 If individual owner/owners, attach copy of your approved document here. Subscribed and sworn to before me this day of, 201 By. Witness my hand and official seal. Date My commission expires: Notary Public 5

The American Legion NATIONAL MEMBERSHIP RECORD

The American Legion NATIONAL MEMBERSHIP RECORD www.legion.org 2016 The American Legion NATIONAL MEMBERSHIP RECORD 1920-1929 Department 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 Alabama 4,474 3,246