Retail Food Establishment Change of Ownership

Transcription

1 Dear Retail Fd Establishment License Applicant: Retail Fd Establishment Change f Ownership If yu are assuming wnership f a licensed retail fd establishment, and yu meet the fllwing cnditins, yu may submit the shrter change f wnership packet rather than the full plan review packet: The facility has been clsed fr less than tw (2) weeks. The menu remains unchanged. The equipment inside is unchanged. The layut f the kitchen is unchanged. If any f the abve cnditins cannt be met, then yu must cmplete and submit all the infrmatin cntained within the Retail Plan Review and Applicatin packet. The Retail Plan Review and Applicatin packet and the Retail Fd Establishment License Applicatin are available n ur website at r frm the health department ffice at the address abve. When the abve cnditins are met, the items n the fllwing list must be prvided t the Weld Cunty Department f Public Health and Envirnment, Envirnmental Health Services Divisin, in rder t accmplish the re-licensing f a facility due t a change in wnership. Failure t prvide infrmatin in full may result in a delay in the licensing f yur facility (additinal items may be required): Retail Fd Establishment License Applicatin Retail Fd Establishment Infrmatin Frm Phtcpy f yur Clrad State Sales Tax License Yur menu r a list f fds that will be served Fire Department Apprval Frm Applicable license fee (see the bttm f the license applicatin fr the categries) **Affidavit and Identificatin verifying legal presence in the United States Nn-Prfit applicants must submit evidence f nn-prfit status (501 C 3). **Clrad Revised Statute ( ) requires that this Affidavit and apprpriate identificatin be prvided t verify that all sle prprietrs and individual applicants fr retail fd establishment licenses are lawfully present in the United States prir t the issuance f the license. Apprpriate types f identificatin are described in the attached Clrad Department f Revenue Emergency Rules fr Evidence f Lawful Presence. Nte Sectin 4 f the Emergency Rules.

2 FOR OFFICE USE ONLY IN# ACCT. I.D. # SR# RETAIL FOOD ESTABLISHMENT INFORMATION FORM OWNER INFORMATION 1. Owner(s) Name 2. Crpratin Name (as it appears n Sales Tax License) 3. Owner Address City State Zip 4. Hme Phne N. ( ) Wrk Phne N. ( ) 5. Owner Mailing Address City State Zip 6. Address: 7. Driver s License N.: (Fr Mbile Establishments Only) ESTABLISHMENT INFORMATION 1. Establishment Name 2. Site Address City State Zip 3. Mailing Address City State Zip 4. Phne Number: ( ) Manager/Cntact Persn 5. State Sales Tax Number: Seating Capacity 6. Hurs f Operatin: Days Su M T W Th F Sa Business Hurs t / t (circle all that apply) 7. Water Supply (check ne) Cmmunity / Public Name f District Nn-Cmmunity / Private PWSID # Well Depth 8. Sewage Dispsal (check ne) Municipal / Public Name f District Individual Sewage Dispsal System Permit # 9. SEND LICENSE/RENEWALS TO: (check ne) Owner Mailing Address Establishment Site Address Establishment Mailing Address Or: 10. CHANGE OF OWNERSHIP ONLY Previus Establishment Name Date f change f wnership : Has facility been clsed fr mre than 2 weeks? Yes N Has Menu Changed? Yes N Has equipment changed? Yes N Has layut f kitchen changed? Yes N Date Owner/Operatr Signature & Title

3 Subject: Implementatin f C.R.S., , et. seq., Restrictins n Public Benefits (HB 1023) T Whm It May Cncern: Yu will find an affidavit included with yur renewal registratin/applicatin. All licenses, certificatins, and registratins issued t individual wners r sle prprietrs by the Clrad Department f Public Health and Envirnment must be accmpanied by verificatin f citizenship. This requirement des nt apply t yu if yu are nt an individual wner r sle prprietr. Verificatin includes cmpleting the affidavit and prviding a ntarized cpy f an apprved identificatin. Apprved identificatin includes: A valid Clrad driver s license r a Clrad identificatin card; A United States military card r a military dependent s identificatin card; A United States Cast Guard Merchant Mariner card; A Native American Tribal Dcument, In additin t the abve listed frms f identificatin, the fllwing will be allwed until March 1, A certificate verifying naturalized status issued by an authrized agency f the United States bearing applicant s intact phtgraph impressed with the raised embssed seal f the issuing agency; A certificate verifying United States citizenship issued by an authrized agency f the United States bearing applicant s intact phtgraph impressed with the raised embssed seal f the issuing agency, r; Other apprved State s driver s license r identificatin card. Nt all states verify lawful presence prir t issuing license. Therefre, nly thse States listed belw are deemed acceptable. 1 Yu may access a ntary in yur area by cnducting a search thrugh directry assistance fr public ntaries. C.R.S., , Restrictins n Public Benefits became effective August 1, 2006, and requires each agency r plitical subdivisin f the state t verify the lawful presence in the United States f every applicant fr public benefits. The law requires the verificatin f citizenship in rder fr persns eighteen years f age r lder t receive certain benefits r btain a license r certificatin frm the department. If the recipient f the benefit is under eighteen years f age, the law des nt apply. If yu need assistance in cmplying with this law r if there is additinal infrmatin yu feel we need t be aware f, please d nt hesitate t cntact me at (970) Alabama, Arizna, Arkansas, Califrnia, Cnnecticut, Delaware, District f Clumbia, Flrida, Gergia, Idah, Indiana, Iwa, Kansas, Kentucky, Luisiana, Maine, Minnesta, Mississippi, Missuri, Mntana, Nevada, New Hampshire, New Jersey, New Yrk, Nrth Dakta, Ohi, Oklahma, Pennsylvania, Rhde Island, Suth Carlina, Suth Dakta, Virginia, West Virginia, and Wyming;

4 AFFIDAVIT - RESTRICTIONS ON PUBLIC BENEFITS I,, swear r affirm under penalty f perjury under the laws f the State f Clrad that (check ne): I am a United States citizen, r I am a Permanent Resident f the United States, r I am lawfully present in the United States pursuant t Federal law. I understand that this swrn statement is required by law because I have applied fr a public benefit. I understand that state law requires me t prvide prf that I am lawfully present in the United States prir t receipt f this public benefit. I further acknwledge that making a false, fictitius, r fraudulent statement r representatin in this swrn affidavit is punishable under the criminal laws f Clrad as perjury in the secnd degree under Clrad Revised Statute and it shall cnstitute a separate criminal ffense each time a public benefit is fraudulently received. Signature Date Firm s Legal Name: Firm s Site Address: Street Unit City Zip

5 LOCAL FIRE DEPARTMENT APPROVAL Please cmplete the fllwing infrmatin and have yur lcal fire authrity representative cmplete the sectin indicated. Once the frm is cmpleted, submit t the address stated belw. Fd Service Establishment Name: Fd Service Establishment Address: City: State Zip Cde: Phne Number : ( ) Tax I.D. Number: Seating Capacity: THIS SECTION TO BE COMPLETED BY FIRE DEPARTMENT Check ne f the fllwing: The abve named establishment meets the requirements fr Fire Department apprval withut further actin by establishment. The abve named establishment des nt meet the requirements fr Fire Department apprval. Please see attached letter. Cmments: Fire Inspectr Name (please print): Title Fire Inspectr Signature: Date: Lcal Jurisdictin: Phne Number: ( ) Please Remit t: Weld Cunty Department f Public Health & Envirnment Attn: Envirnmental Health Services 1555 N. 17 th Avenue Greeley, CO Phne (970) Fax (970)

6 Fr Agency Use Only WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 Nrth 17th Ave, Greeley, CO Retail Fd Establishment License Applicatin (as f September 1, 2018) Incmplete applicatins, r applicatins withut payment (if required), will nt be prcessed. Ownership type: Individual (must cmplete affidavit f residency) Crpratin (LLC, LLP, S-Crp, etc.) Nn-prfit (includes gvernment) Other Full legal name f wner, crpratin, r nn-prfit: Trade name (DBA): Cntact name (n site): CO Sales Tax Acct. N. Physical address f business: City: State: Zip: Cunty where business is lcated: Phne number: Other cntact number (mbile, fax, etc.): Mailing address (if different frm abve): City: State: Zip: Date yu started the business: Seasnal? Mark each mnth yu perate: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC In cnsideratin theref, I d hereby certify that I have cmplied with all items f sanitatin as listed in the Clrad Retail Fd Establishment Rules and Regulatins (6 CCR ), and that I have cmplied with all rders given me by authrized inspectrs f the Clrad Department f Public Health & Envirnment, r lcal bard f health. I als agree that in the event sanitatin items are nt cmplied with, I will discntinue serving fd until such time as requirements are met. Signature: Title: Date: Calendar Year: Check the apprpriate license type frm the list belw. This is yur license fee. License Type Cde Fee N fee license (K-12 schls, nn-prfits) 1000 $0.00 Limited fd service (cnvenience, ther) 2000 $ Restaurant (0 100 seats) 3000 $ Restaurant ( seats) 3100 $ Restaurant (> 200 seats) 3200 $ Grcery stre (0 15,000 sq.ft.) 4000 $ Grcery stre (> 15,000 sq.ft.) 4150 $ Grcery stre w/ deli (0 15,000 sq.ft.) 5000 $ Grcery stre w/ deli (> 15,000 sq.ft.) 5150 $ Mbile unit (prepackaged) 6200 $ Mbile unit (full fd service) 6300 $ Oil & Gas Temprary 7000 $ Special Events 8000 Set lcally Please remit payment t: Weld Cunty Department f Public Health & Envirnment 1555 Nrth 17th Avenue Greeley, CO T pay with a credit card, please call: Ttal Due: $