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Food Establishment Application Goldendale Office Klickitat County Health Department White Salmon Office 228 West Main Street 501 NE Washington St/ PO Box 159 MS-CH 14 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] A person wanting to operate a new food establishment shall submit a permit application and a plan review packet at least 30 calendar days prior to the desired date of opening. Renewal applications must be submitted prior to your expiration date. New owners are required to submit a new application at least 2 weeks prior to the change of ownership. New owners are subject to a change of ownership fee. A change of ownership may require an initial inspection by your sanitarian. In Klickitat County your facility’s yearly operating permit is based on an operating fee and a complexity fee. Establishments limited to a specific menu/operation have a flat operating fee and are not charged on complexity level, those are highlighted below. New construction for an establishment or remodel of an existing establishment is subject to plan review requirements and fees. Level I Complexity: Menu or service items are limited to prepackaged non-PHF or prepackaged PHFs that require cold holding. Menu items may include snacks, baked goods, dairy products, prepackaged deli meats (cold), frozen prepackaged burritos, prepackaged sandwiches or salads Level II Complexity: Menu or service items are limited to simple cooking, heat for service, heat for hot holding, or food preparation of ready to eat foods (salads, sandwiches). Menu items may include soups, hamburger cooked for immediate service; product is cooked to the proper temperature and served immediately or hot held at 135F Level III Complexity: All processes in complexity I and II are allowed. Further processes include proper cooling procedures. Complex cooking procedures or complex processes are allowed. Processes include acidification, cook-chill, reduced oxygen packaging, smoking, sous-vide or other processes. All complex process require a variance and HACCP Please mark the boxes below that correlate with the type of establishment you operate. Operating Hours If you are operating seasonally, please provide the months of operation: Type of Establishment Establishment w/ Public Sewer 170 Establishment w/ OSS 190 Bed and Breakfast w/ Public Sewer 175 Bed and Breakfast w/ OSS 195 Catering 50 Farmers Market 80 Community Kitchen 80 School Kitchen 150 School Satellite 50 Complexity Level Level I 0 Level II 125 Level III 175 Plan Review Fees New Construction 150 Remodel 100 Change of Ownership 100 Sunday Monday Tuesday Wednesday Thursday Friday Saturday ---PAGE BREAK--- Food Establishment Application Goldendale Office Klickitat County Health Department White Salmon Office 228 West Main Street 501 NE Washington St/ PO Box 159 MS-CH 14 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Is this a new application, change of ownership, or renewal? Facility Information Name: Address: City: State: Zip: Facility Phone: Commissary Address (if applicable): City: State: Zip: Contact/Mailing Information Name: Mailing Address: City: State: Zip: Contact Phone: Contact Email: Owner Information Corporation Name: Individual Name: UBI Number: Owner Address: City: State: Zip: Owner Phone: Owner Email: Applicant’s signature: Date: As the manager and or owner/operator of this facility, I do hereby make application for a permit to operate a food service establishment in compliance with the Rules and Regulations of the State Board of Health for Food Service Chapter 246-215 WAC. I understand that this permit is NON-REFUNDABLE and NON-TRANSFERABLE to a new owner or location.