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PLC:

a0039y

Agency:

bayfield county health department

For:

environmental health

Phone:

715-373-6109

Address:

117 east sixth street
washburn, wisconsin 54891

*Required Field

Payment Information

Business Name and Facility Name are required fields if applicable.

*Name:

Middle:

*Last:

*Facility Name:

Retail Foods Serving Meals License:

Retail Foods Serving Meals Pre-inspection Fees:

Retail Foods Not Serving Meals License:

Retail Foods Not Serving Meals Pre-Inspection Fees:

Temporary Event Food Permit:

Mobile Food Establishments License:

Mobile Food Establishment Pre-Inspection Fees:

Mobile Service Base License:

Mobile Service Base Pre-Inspections:

Lodging License:

Lodging License Pre-inspection Fees:

Recreational Facilities License:

Recreational Facility Pre-inspection Fees:

Recreational Facilities requested:

Campground License Fees (Special Event Campground does not require Pre-Inspection Fees):

Campground Pre-Inspection Fees::

Tattoo and Body-Piercing Establishments License:

Tattoo and Body-Piercing Establishments Pre-Inspection Fees:

Other Fees:

Other Fees..:

Well Water Testing Fees 1:

Well Water Testing Fees 2:

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number: