Microsoft Word - WCHD_Food_&_Beverage_Permit

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EH222967EXAPP | REV12212022

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

555NorthCourtStreet,Rockford,IL61103  

Mailto:P.O.Box4009,Rockford,IL61110‐0509

Phone:(815)720‐4100Fax:(815)720‐4203

Email:[email protected]incoil.gov

Website:publichealth.wincoil.gov

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ApplicationforFoodandBeveragePermit 

FoodandBeveragePermitsarenon‐transferableandnon‐refundable.Instructionsforapplicationprocessingareonthenext

page.Pleasereadcarefullytoensurethattheinformationyouprovideiscompleteandaccurate.MOBILEVENDORSshould

haveamobileunitspecificapplication.

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FacilityName:_____________________________________FacilityAddress:__________________________________

City:______________________________________________State:___________ZipCode:____________________

PhoneNumber:___________________Ext._____________FaxNumber:___________________________________

Email:__________________________________________Website:_________________________________________

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WaterService:

⬜City ⬜PrivateWell(ifPrivateWell,submitcopyofcoliformandnitrateteststakenwithinthelast12months)

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SewerService:

⬜City ⬜Septic(ifSeptic,submitmostrecentpumpingreceipt)

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Seasonal:

⬜Yes⬜

No

(ifSeasonal,submitdates:OPENINGDATE:_________________CLOSINGDATE:___________________

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Catering:

⬜Yes⬜

No

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CertifiedFoodProtectionManager:_________________Certificate#:____________ExpirationDate:____________

DaysofWeekOpen

:⬜Sunday⬜Monday⬜Tuesday⬜Wednesday⬜Thursday⬜Friday⬜Saturday

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OpeningTime:____________________

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Owner:_______________________________________Owner’sAddress:____________________________________

City:_______________________________________________State:___________ZipCode:___________________

PhoneNumber:___________________________Email:__________________________________________________

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MailPermitTo:_________________________________Address:___________________________________________

City:_______________________________________________State:___________ZipCode:___________________

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ItheApplicant,herebystateIamfamiliarwiththeprovisionsoftheHealthOrdinanceofWinnebagoCountyandthatIwilloperate

thisestablishmentincompliancewithsaidprovisionsatalltimes.

ApplicantsSignature:_______________________________________Date:___________________________________

FOROFFICEUSEONLY

CountySanitarianSignature:_________________________________Date:___________________________________

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Submitcompletedapplication,supportingdocuments,andregistrationfeetotheWinnebagoCountyHealthDepartmentbyoneofthefollowingmethods:

InPerson:555N.CourtSt.,RockfordIL∙Mail:P.O.Box4009,Rockford,IL61110‐0509∙Email:environmental@publichealth.wincoil.gov

Feemaybepaidwithcash,check,card,oronE‐PAYat:https://publichealth.wincoil.gov/how‐do‐i/get‐a‐permit‐or‐license/

FOROFFICEUSEONLY

Date:___________________________________

Amt.Rec’d:______________________________

Check/Cash/Credit/E‐PAY:__________________

ReceiptNo.:_____________________________

PermitNo.:______________________________

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EH222967EXAPP | REV12212022

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APPLICATIONINSTRUCTIONS:

FilloutapplicationinitsentiretyandreturnittotheWinnebagoCountyHealthDepartment(WCHD)together

withtherequiredfeebasedonthefeeschedulebelow.Delaysinpermitmailingmaybetheresultofanincompletepermitapplicationform.

MakecheckspayabletoWCHD.Iftheestablishmentisownedbyacorporation.Thenamesandaddressesofthecorporationofficersmust

beprovided.

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FORNEWOWNERORNEWFACILITY:

Reviewofthefacility,menuandoperationisrequired,therefore,theapplicationmustbepre‐

approvedbyaHealthInspectorpriortosubmittinganypayment.WARNING:Refundmaynotbegrantedforanypaymentwithoutapre‐

approvedapplication.

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Thetablebelowshowsthedaterangeforwheneachtypeofpermitisvalid.

PermitType PermitStartDate DatePermitExpires

HighRisk April1

 March31st

MediumRisk July1st June30th

LowRisk October1st September30th

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Belowaretheduedatesfortherenewalapplicationforeachtypeofpermit.

Alatefeeshallbeassessedifthe renewal application and applicablefeesarenotreceivedorpostmarkedbythe1

late feedate as

described in the table below. A second late fee will be assessed if the renewal application and applicable fees are not received or

postmarkedbythe2

latefeedateasdescribedinthetablebelow.

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FEESCHEDULEandCLASSIFICATION

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Regardlessofwhetherconsumptionison,inoroffthepremisesorifthereisachargeforthefood,afoodpermitisrequired.Thisprovision

excludesprivatehomeswherefoodispreparedforindividualfamilyconsumption.

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HighRisk(CategoryI)–Feeasdeterminedinchartbelow

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AHighRiskpermitisrequiredforallestablishmentswherefoodispreparedforindividualserviceasdescribedbelowandwhere

potentiallyhazardousfood(s)are:

Seating0‐50 $500.00

1. Extensivelyhandled,completelyprepared,andcooled;

2. Heldhotorcoldfortwelvehoursormorebeforeserving;

3. Reheatedafterpreviouslyhavingbeencookedandcooled,

4. Preparedforoff‐premisesservice;

5. Requiredtohavetime‐temperaturecontrols;

6. Sealedinreducedoxygenpackaging;

7. Servedtopredominatelyimmune‐compromisedpopulations.

Seating51‐100 $555.00

Seating101‐150 $605.00

Seating151‐200 $655.00

Seating200+ $710.00

Allschoolsandnursinghomeswill

bechargedaflatfeeof$500.00

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⬜

MediumRisk(CategoryII)‐$285.00

AMediumRiskpermitisrequiredforallestablishmentsthatholdhotorcoldfoods:wherefoodispreparedforindividual

serviceasdescribedbelowandwherepotentiallyhazardousfood(s)are:

1. Heldfornotmorethantwelvehoursbeforeserving.

2. Notreheated;

3. Preparedfoodsforservicefromrawingredientsusingonlyminimalassembly;

4. Obtainedfromanapprovedsourceinapreparedstatewhencomplexpreparationisrequired.

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⬜

LowRisk(CategoryIII)‐$170.00

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ALowRiskpermitisrequiredforallestablishmentshavingonlypre‐packagedfoodsand/ordispensedbeverages.

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Ifyouhaveanyquestionsregardingtherisklevelortypeofpermityoushouldapplyfor,pleasecontactWCHDat815‐720‐4100.

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 DONOTchangeyourrisklevelwithoutconsultingWCHDfirst.(815)720‐4100.

 PermitsWILLNOTbeissueduntil,allcurrentandoutstandingfeesarereceived.

PermitType

RenewalApplications

DueDate 1stLateFeeDate: 2

LateFeeDate: Penalty/LateFee

HighRisk APRIL1 APRIL15 MAY15 $75.00EACH

MediumRisk JULY1 JULY15 AUGUST15 $75.00EACH

LowRisk OCTOBER1 OCTOBER15 NOVEMBER15 $25.00EACH