Public Health Change of Ownership

Establishment information
Owner information
Operator information
Basic establishment
Contact Information

Please submit this form with a menu (food establishments only). A license application and invoice will then be prepared and sent to the new owner. Permits to operate and annual license are NOT TRANSFERABLE. Hennepin County's licensing year runs from February 1st through January 31st.

Establishment information(physical location)

Establishment name

Phone number

Address

City

State

Zip Code

Owner name (as it will appear on the license)

Phone number

Address

City

State

Zip Code

Operator different from owner

Operator name

Phone number

Address

City

State

Zip Code

No change of facilities

Remodel planned (plan review may be required)

Date of ownership transfer

Anticipated opening date (if establishment closed)

Food service

Number of kitchens

Number of bars

Capacity

Seating

Customers per day

Lodging (if applicable)

Number of units

Children's camps (if applicable)

Number of units

Types of service (provide a brief description of the basic types(s) of food/beverage service & the nature of the operation)

Menu information (attach copy of menu & provide basic delivery information/sources here)

Employee involvement (provide information on the number & category of workers - include total & per shift)

Include attachments below

Name

Phone number

Email address

Confirm email address

Signature

Date

Reviewed all

I have reviewed all of the information and believe it to be correct.