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P.O. Box 281Nashville IN 47448812/988-2255812/988-5601 FAX0-8890 Brown County Department of Health bchealth@browncounty-in.usNorman Oestrike, MD Health Officer APPLICATION for a LIMITED FOOD LICENSE January 1, 2021 to December 31st 2021 (payment not to be made before January 4th)(Operation of A Retail Food Establishment serving only pre-packaged food requiring no preparation, but possibly requiring some refrigeration/freezing)Application is hereby made for a license to operate a retail food establishment with a limited food selection restricted to only pre-packaged food that may require refrigeration and freezing. By this application, it is agreed that the establishment will comply with the provisions of the Indiana State Department of Health Rules 410 IAC 7-24, 410 IAC 7-15.5, and Brown County Ordinances 08-17-98-01, 11-18-96. It is further agreed that the establishment shall be open to inspection by agents of the Brown County Health Department. THIS PERMIT IS NOT TRANSFERABLE –new ownership needs a new permit. Payment must be made between January 4th and January 29th unless you are a seasonal operation. There is a 10% a day late fee for payments later than January 29th.BCHD can accept:Check, Credit/Debit Card, Cashier’s Check, Cash or Money Order,(The Brown County Health Department reserves the right to refuse a check, and there is a 3% fee on credit or debit cards. We can take credit/debit information over the phone)THIS SIGNED ORIGINAL FORM MUST BE RETURNED TO OUR OFFICE even if you pay online with a credit/debit card Checks are to be made payable to the Brown County Health Department, P O Box 281, Nashville IN 47448The fee is not refundable. Submitting this application does not guarantee a license will be issued.Name of Establishment:____________________________________________________ The name commonly used or the "doing business as" name. Mailing Address:________________________________________State:____Zip:_____The legal mailing address of the business-this may or may not be the same as the street locationStreet Location of Establishment: ____________________________________________Phone: (_______)__________________ Emergency Phone: (_____)________________In case of emergency, if business is closedBusiness Operator's Name:_________________________________________________The person or corporation that owns the business.Business Owners Mailing Address: __________________________State:___Zip:_____Business Owner’s Phone/Cell: (_______)_____________________________________E-Mail Address: ________________________________@_________________________If the operator or manager has an e-mail address, please show it here.Website Address:_________________________________________________________If the business has a web address-not requiredOn-Site Manager's Name:___________________________________________________This person is responsible for the daily operation at the business location. Building Owner's Name: ___________________________________________________The person or company that owns the building that is housing the business. Food Items: ________________________________________________________________________________________________________________________________________________________________________________________________________________ALL Freezers and cooling units are required to have a temperature measuring device..Establishment’s Daily Opening & Closing Times: ______________________________Is this a Seasonal Operation? Yes___ No___ If yes – opening date______________Public Water Supply?: ___Yes ___No Is the business served by a public utility?Public Sewage Disposal?: ___Yes ___No If private septic system or sewage disposal, mark "no".NO CERTIFIED FOOD MANAGER REQUIRED - This establishment is exempt by menu (only pre-packaged foods)Title 410 IAC 7-22-15(g) isdh/regsvcs/foodprot/foodhandler/certificationrule.htmI attest to the accuracy of the information provided herein;Signature: _____________________________________________________________Print Name: __________________________________________Date: _____________Title: __________________________________________________________________The person who fills out the application needs to sign this application, plus indicate their title.Food License Fee: 1-5 Employees-$120.00 6-9 Employees-$240.00 10 or more-$300.00 Do not write below this line. For office use only.? 1 Pre-packaged, Non PHF, no Modified Atmosphere Packaging or ROP, no food preparation, cooking, cooling, reheating.Assigned Risk Category: 1Payment Received: $_______________ Date License Issued: ______________________

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