ENVIRONMENTAL HEALTH SERVICE REQUEST FORM 2019

Transcription

1 (719) phone (719) fax ENVIRONMENTAL HEALTH SERVICE REQUEST FORM 2019 Owner Name: : Owner Address: Establishment/Business Name: Establishment/Business Address: Phone Fax: Address: Air Quality Construction Activity Permit (Per Six Months) $ per six months Body Art Body Art Regulations Competency Exam $30.00 per attendee # Body Art Plan Review (incl pre-opening inspection) $ Body Art Establishment License $ Follow-Up Inspection $75.00 Body Art Change in Ownership $ Temporary Event Fee $ per vendor Retail Food Safety Food Handler Training $15.00 per attendee # Review of Potential Retail Food Establishment Site $75.00 or actual cost at $62.00 per hour, whichever is greater Change in Ownership Inspection $ (non-refundable) Change in Ownership Inspection (Additional Inspection) $65.00 (non-refundable) RFE Plan Review Application $ (non-refundable) RFE Plan Review initial minimum time: 90 min at $62.00 per hour $93.00 Special Event License- Full Menu $ per 1 Day Event $ per 1-8 Day Event $ Multiple Events Special Event License-Limited Menu $75.00 per 1 Day Event $ per 1-8 Day Event $ Multiple Events RFE Plan Review and Pre-Opening Inspection $62.00/hour not to exceed $ To be calculated RFE Equipment/Product Review Application $ (non-refundable) RFE Equipment/Product Review $62.00/hour not to exceed $ To be calculated RFE HACCP Plan Review (Written) $62.00/hour not to exceed $ To be calculated RFE HACCP Plan Review (Operational) $58.00/hour not to exceed $ To be calculated RFE Other Services Requested $62.00 per hour To be calculated On-Site Wastewater Treatment System (OWTS) OWTS Installer Exam Tier 1 (2 year license) $ per 2-Year License OWTS Installer Exam Tier 2 (2 Year license) $ per 2-Year License Certified Inspector $ per 2 year Certified O and M Specialist $ per 2-year OWTS Return Trip Fee $90.00 OWTS Variances $59.00 per hour (non-refundable) To be calculated Altered/Renewed OWTS Permit $90.00 per permit Revision 2019 Board of Health Approved Fees

2 Pumper Truck Inspection (Systems Cleaner) $90.00 per truck OWTS Transfer of Title Acceptance Document $55.00 OWTS Transfer of Title Acceptance Document Renewal $27.00 OWTS Permits (New and Repair) Complete OWTS Application Compliance and Enforcement Certificate of Non-Compliance Release $ Administration Copy of State/Local Regulations File Search $50.00 Non-Sufficient Funds $30.00 $5.00 per copy Other Administrative Requested Services $30.00 per hour Plan Review $ Inspection Year Around Pool/Spa $ Inspection Seasonal Pool/Spa $ Follow-Up Inspections Additional Body(s) of Water Additional Services Recreational Water Program Recreational Water (Commercial Pools/Spas) $62.00 per hour $35.00 per body of water $62.00 per hour Child Care Inspection Type of Facility Routine Pre-Operational Follow-Up Room Change Child Care $ $ $75.00 $80.00 School Age (Before and After) $ $ $75.00 $80.00 Preschool $ $ $75.00 $80.00 Group Homes $ $ $75.00 $80.00 Residential Summer Camps $ $ $75.00 $80.00 Large Summer Camps $ $ $75.00 $80.00 Residential/Day Treatment Center $ $ $75.00 $80.00 Child Care Plan Review (including pre-operational inspections) $ TOTAL FEES $ Applicant Signature Environmental Health Specialist

3 F (719) phone (719) fax Retail Food Establishment License Application Calendar Year 2019 Incomplete applications, or applications without payment (if required), will not be processed. Ownership type: 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: Mailing address (if different from above): City: State: Zip: 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: : Calendar Yr: License Type Code Fee No fee license (K-12 schools, non-profits) 1002 $0.00 Limited food service (convenience, other) 1004 $ Restaurant (0-100 seats) 1007 $ Restaurant ( seats) 1012 $ Restaurant (> 200 seats) 1016 $ Grocery Store (Under 15,001 sq. ft.) 1021 $ Grocery Store (Over 15,000 sq. ft.) 1029 $ Grocery Store w/ deli (Under 15,001 sq. ft.) 1049 $ Grocery Store w/ deli (Over 15,000 sq. ft.) 1059 $ Mobile unit (prepackaged) 1089 $ Mobile unit (full food service) 1085 $ Special Event (full menu) Special Event (limited menu) Total due: $ $ per 1 Day Event $ per 2-8 Day Event $ Multiple Events $75.00 per 1 Day Event $ per 2-8 Day Event $ Multiple Events Make checks payable to EPCPH. Mail payment and completed application to: El Paso County Public Health 1675 W Garden of the Gods Rd, Ste 2044 Questions? Call: Visit: County Use Only Health Specialist elpasocountyhealth.org healthinfo@elpasoco.com Rev 08/2018

4 El Paso County Public Health (719) OWNER/CONTRACTOR CONTACT INFORMATION Today s : TYPE OF ESTABLISHMENT: Retail Food Body Art On-Site Wastewater Contractor Other Systems Cleaner OWNER INFORMATION: Type of Ownership: Individual Partnership Corporation Owner Name: Owner Address: City: State: Zip: Phone: Cell Phone: Fax: Address: ESTABLISHMENT/BUSINESS INFORMATION: Establishment/Business Name: Establishment/Business Address: City: Rev. 1/3/2012 Zip: Establishment/Business Phone Number: Fax: Days/Hours Of Operation: Retail Food Only: Total building square footage (if grocery store): # Seats (if restaurant): ALTERNATIVE CONTACT INFORMATION (Two contacts other than owner): 1. Name: Title: Phone: Cell Phone: Fax: Address: 2. Name: Title: Phone: Cell Phone: Fax: Address:

5 El Paso County Public Health Certification of Commissary Definition A commissary means an approved catering establishment, restaurant, or other approved place in which food, containers, or supplies are kept, handled, prepared, packaged or stored. Signatures Required: The owner/operator of the mobile unit or food booth shall complete and sign PART 1. The owner/operator of the commissary shall complete and sign PART 2. ****************************************************************************** PART 1 Mobile Unit/Food Booth Name: Owner name of mobile unit: Retail food establishment license year CERTIFICATION OF OWNER OF MOBILE UNIT/FOOD BOOTH By signing below, I here by state that I will use the facility listed below as my commissary for the preparation and storage of food items, cleaning of equipment and utensils and other uses as mandated by the Colorado Retail Food Establishment Rules and Regulations. Signed Check here if this is the same commissary used in the previous retail food license year. Check here if this is not the same commissary used in the previous retail food license year. ***************************************************************************** PART 2 Name of Commissary: Address: City, State, Zip County where located: Owner/Manager: Phone: CERTIFICATION OF COMMISSARY OWNER By signing below, I hereby state that I am the owner/manager of the above commissary and I have authorized the owner of the above referenced mobile unit/food booth to use my facility as a commissary for the storage and preparation of food and, if applicable, the washing and sanitizing of equipment and daily servicing of the mobile food unit. Authorization is valid through the end of the mobile unit retail food license year. Signed FOR HEALTH DEPARTMENT USE ONLY Needs pre-license inspection within 48 hours Completed by: Rev. 1/3/12