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FOOD ESTABLISHMENT APPLICATION Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Please review the following; Is this a renewal application? ☐ Yes ☐ No Has your contact information changed? If so, please fill out the contact section on the following page. ☐ Yes ☐ No Is this a change of ownership? ☐ Yes ☐ No Has your approved menu processes changed? ☐ Yes ☐ No Have you done any kitchen remodeling? ☐ Yes ☐ No A change of ownership or menu change may require an initial inspection by your sanitarian and subject to the applicable plan review fees. TCS Foods are foods that require temperature or time as a public health control. LOW RISK: Limited food prep: menu or service items are limited to prepackaged Non-Temperature Control for Safety foods (TCS) or prepackaged TCS foods that require cold holding. Menu items may include snacks, baked goods, dairy products, prepackaged deli meats (cold), frozen prepackaged burritos, prepackaged sandwiches or salads using commercially prepared produce (washed lettuce or bagged lettuce). MODERATE RISK: Raw food preparation: menu or service items are limited to preparation of raw meats, washed or sliced fresh fruits and vegetables (TCSs), and do not cool cooked TCS foods. This may include delis, quick service, sandwich shops, or grocery stores with limited menu items. HIGH RISK: Advanced food preparation: menu or service items that may have been cooked and then cooled; such as pasta salads, leftovers, pulled pork, or TCS food that is cooled and further processed. This may also include specialized processes like; smoking, curing, vacuum packaging, or if you need to have a consumer advisory. This may include restaurants, buffets, or large grocery stores with a deli. Please mark the box below that correlates with your type of operation. TYPE OF ESTABLISHMENT ☐ Low Risk Establishment ($250) ☐ Community Kitchen ($200) ☐ Moderate Risk Establishment ($500) ☐ Change of Ownership ($100) ☐ High Risk Establishment ($750) ☐ School Kitchen ($250) ☐ Mobile Unit Low Risk ($250) ☐ School Satellite ($100) ☐ Mobile Unit Moderate Risk ($350) ☐ Bed and Breakfast ($300) ☐ Mobile Unit High Risk ($500) ☐ Catering ($100) ---PAGE BREAK--- FOOD ESTABLISHMENT APPLICATION Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] Health Department Use Only FACILITY INFORMATION Facility Name: Site Address: City: State: Zip: Facility Phone: HOURS OF OPERATION ☐ Open 24 Hours a day ☐ Seasonal Operation ☐ Annual Operation If seasonal, provide months of operation: Sunday Monday Tuesday Wednesday Thursday Friday Saturday As the owner and 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 this permit is NON-REFUNDABLE and NON-TRANSFERABLE to a new owner or location. Applicant’s signature: Date: OWNER INFORMATION Name: Mailing Address: City: State: Zip: Owner Phone: Owner Email: