FOOD ESTABLISHMENT LICENSE APPLICATION

FOOD ESTABLISHMENT LICENSE APPLICATION
In order to properly process your application Racine County Public Health Division (RCPH) requires a copy of your proposed menu, a list of your food equipment (name, manufacturer, model number), and a floor plan. Construction plans may be required if construction or remodeling will occur.
LEGAL NAME OF OWNER (INDIVIDUAL, LLC. INC OR OTHER)*
MAILING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF CONTACT*

First NameLast Name
TITLE OF CONTACT
CONTACT PHONE*
Please enter a valid phone number.
CONTACT EMAIL*
example@example.com
ESTABLISHMENT NAME
ESTABLISHMENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ESTABLISHMENT PHONE
Please enter a valid phone number.
ESTABLISHMENT EMAIL
example@example.com
Facility Type

Fixed Permanent FacilityMobile Facility
Information requested on this application must be provided to obtain an establishment license. Personal information you provide may be used for purposes other than that which it was collected (s. 15.04(1)(m), Wis. Stats.). Operating without a license is a violation of Wisconsin Law. If you have been operating without a license, you will be required to pay a surcharge in addition to the license fee. Licenses are not transferable between persons or locations. Licenses expire annually on June 30. The license fee is not prorated for partial license years. The Public Health Division may inspect premises at any reasonable time. Missing information may delay the issuance of your license. The undersigned hereby certifies that this is a true, complete, and accurate application.
Signature*

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Print Name*
Date*

MonthDayYear
Date

For Health Department Use Only

License Fee
Pre-Inspection Fee
*Plan Review Fee
Total Amount

*A plan review may be required if there will be construction or remodeling.
Should be Empty: