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Environmental Health <br /> ll� RAMSEY COUNTY 2785 White Bear Ave. North Swte 350 <br /> Saint Paul — Ra►nsey County Public Health Maplewood,MN S5109 <br /> 651-266-1199 <br /> ramseycounty.us <br /> LICENSE TYPE WORKSHEET <br /> Instructions: Applicant must fill out the applicable area(s) below to be issued the correct license types. <br /> FOOD(CHECK ALL THAT APPLY) <br /> Open Food or Packaged Food IE5bpen ❑Packaged ❑ Both <br /> Cold Food Temperature Control -Refrigerated for Safety Food ❑ Unrefrigerated Food ❑ Both <br /> Hot Food Temperature Control ooking raw animal food(s) <br /> Mot holding cooked food(s) <br /> Reheating already cooked food(s) <br /> Food Cooled On-site Hot food is cooled ❑ Room temperature or pre-chilled food is cooled ❑Both <br /> Additional Food Service Activities ❑Off-site Catering Bar Service El On site Cafeteria or Buffet Service <br /> Special Processes to Preserve Food ❑Acidifying ❑Smoking ❑ Curing ❑ Fermenting ❑Vacuum Packaging <br /> (ex:sushi rice, sauerkraut,kimchi,etc.) ❑ Other: <br /> Gross Annual Retail Food Sales ❑ Less than$50,000 ❑$50,000 to$250,000 ❑$250,000 to$1,000,000 <br /> (Retail Food means packaged or bulk ❑$1,000,000 to$5,000,000 ❑ $5,000,000 to$10,000,000 <br /> foods intended for eating off-site) ❑ More than$10,000,000 <br /> Describe the food establishment type ` i 1 �`v^ 'Q , c J. C �)CkvI <br /> (ex: Fast food,grocery store, bakery, \ <br /> supper club,school cafeteria, daycare) <br /> Note: You may be contacted by your area inspector to discuss types of food offered for sale or service to ensure correct license. <br /> LODGING <br /> Number of Guest Rooms: I <br /> SWIMMING POOLS/SPAS <br /> ❑ Indoor Pools# ❑Indoor Spas tt <br /> Number of Pools and Sp s: ❑ Indoor Slide Pools# ❑ Indoor Wading Pools# <br /> J ❑Outdoor Pools# ❑Outdoor Spas# <br /> O Outdoor Slide Pools# ❑Outdoor Wading Pools# <br /> MANUFACTURED HOME PARK/RECREATIONAL CAMPING AREAS <br /> Number of Home/Camping Sites: <br /> END OF LICENSE APPLICATION <br /> INSPECTOR USE ONLY <br /> License type fee code(s): Risk Category: ❑Low ❑Medium ❑High <br /> Other license types at same establishment: ❑Food ❑Lodging ❑Swimming Pool ❑MHP/RCA ❑Youth Camp <br /> Fee Adjustments: O Prorated Fee ❑Late Fee ❑Food Waste Diversion Discount <br /> Plan Review: ❑Completed I]In-progress ❑Not Started ❑ Not Applicable(Change of Owner Only) <br /> Reviewing Inspector: Date: License Delivery: <br /> O Email ❑Mail ❑By Area Inspector <br /> Comments: State Delegation: ❑MDH ❑ MDA <br /> ADMIN USE ONLY <br /> Date Received: Invoice Amount: DHD license#: Fee Statement#: Entered By: <br /> 2 <br /> 8.29.2023 <br />