2014/09/23 - LAND USE - CUP - Conditional Use Permit

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DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public health Bureau of Environmental and Occupational Health F-47013(Rev.02/12) Chapter 254,Subchapters IV and VII (508)266-2835 STATE OF WISCONSIN PERMIT APPLICATION Completion of this form is voluntary, however to receive a permit you must complete the form. To receive a permit send the completed application and feels),check or money order,payable to the Department of Health Services. Incomplete information may delay processing your application. For complete mailing address,see attachment. Type or Print Only Application is for: K New Establishment ❑ Change in Ownership ❑ Other, please specify Establishment Name GyiG Qti� -r�(Q�p -,b r^^V_ County �)UY (\0- Establishment Street Address,City, State an Zip ode Establishment Telephone 3fi, 3�Re.fCA Lade f� k'v I wy fl � o ( �1s ) Legal Li ensee(such s name of sole ropnetor or partnership,or LLC,LLP, Inc.) E-mail Address Q i . Cofn Licensee Street Address,City, Slats and Zip Code Legal Licensee Tel hon- ZU l 1 ) d5 2lam Name of Agent for the Corporation/Operator(if applicable) Intended Date of Opening for Business I Name of Farmer Business ^^^� Name of Former Operator nom^ ID No. �)OnQ. Check appropriate category for each of the following section. FOOD SERVICE ❑ Prepackaged off-premise $ 235.00($105.00 Permit fee+$130.00 Preinspection fee) ❑ Full-service-Simple- 5 550.00($230.00 Permit fee+$320.00 Preinspection fee) ❑ Full-service-Moderate' $ 800.00 ($330.00 Permit fee+$470.00 Preinspection fee) ❑ Full-service-Complex' $1310.00($540.00 Permit fee+$770.00 Preinspection fee) ❑Additional Food Prep Area $ 80.00 (within establishment) -To be determined by Inspector at time of inspection State of Wisconsin Restaurant Manager Certification ID No.: Expiration Date: LODGING Number of Sleeping Rooms rA Tourist Rooming House(1-4 rooms) $ 410.00 S 110.00 Permit fee+$300.00 Preinspection fee) lO (Cabin, Collage,etc.) -70u. --1 V� ❑ Hotel/Motel/Resort IS 30 rooms) S 685.00($205.00 Permit fee+$ 480.00 Preinspection fee) ❑ Hotel/Motel/Resort(31-99 rooms) $ 945.00($280.00 Permit fee+$ 665.00 Preinspection fee) ❑ Hotel/Motel/Resort(100-199 rooms) $1150.00($355.00 Permit fee+ $ 795.00 Preinspection fee) ❑ Hotel/Motel/Resort(200+rooms) $1675.00(5490.00 Permit fee+ S1185.00 Preinspection fee) ❑ Bed 8 Breakfast(8 or less rooms) S 410.00($110.00 Permit fee+S 300.00 Preinspection fee) Hotel/Motel operator, please advise us as to which you want to be classified as: ❑ Hotel ❑ Motel If a lodging facility,do you have food service for tourists,transients or guests on your premisesv ❑ Yes 0 No CAMPGROUND Number of Sites ❑ Campground (1-25 sites) $ 555.00(5175.00 Permit fee+$380.00 Preinspection fee) ❑ Campground (26-50 sites) S 815.00(5250.00 Permit fee+ $565.00 Preinspection fee) ❑ Campground (51-100 sites) $1005.00($305.00 Permit fee+$700.00 Preinspection fee) ❑ Campground (101-199 sites) $1185.00($355 00 Permit fee+ $830.00 Preinspection fee) ❑Campground(200+sites) $1375.00(5410.00 Permit fee+ $965.00 Preinspection fee) If a campground facility, do you have food service for patrons? ❑ yes ❑ No Layout and plan must be submitted with application for new and remodeled camps. RECREATIONAL 8 EDUCATIONAL CAMP ❑ $1705.00(5505.00 Permit fee+ $1200.00 Preinspection fee)