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2. This is a food establishment certification of 1) No change to facilities or 2) Renovations/Alterations to facilities
4. It is the responsibility of the food establishment to disclose information on renovations and alterations to the City of Dubuque. Alterations found during inspections not previously submitted to the City of Dubuque will result in a penalty. Please indicate below, any renovations or alterations made in the plumbing, menu, appliances, or any other changes that correlate to the fats, oils, and grease (FOG) program:
6. Name of establishment*
7. Name of Corp., LLC, LLP, etc.
9. Permit #:*
   This is a four-digit number and remains the same from year to year unless there is a change in ownership. It is indicated on current permit or hauler manifest. (See example at right.) If the permit number is unknown, call 563-589-4176.
10. Sample Permit Number
    
12. Renovations/Alterations
    Please indicate any below:
14. Plumbing*
    -- Select One --YesNo
16. Summary of Plumbing Alterations (if applicable)
18. Menu*
    -- Select One --YesNo
20. Summary of Menu Alterations (if applicable)
22. Attach copy of new menu (if applicable)
24. Please indicate any changes to appliances or fixtures.*

    1. No changes
    2. Deep fryer
    3. Grill
    4. Oven
    5. Rotisserie
    6. Garbage grinder

    1. Pre-wash sink
    2. Tilt kettle
    3. Floor drains
    4. Three-compartment sink
    5. Two-compartment sink
    6. One-compartment sink

    1. Hot dog roller
    2. Work range
    3. Dishwasher
    4. Mop sink
    5. Other (please indicate below)
26. Summary of Appliance/Fixture Alterations
28. Summary of Any Other Alterations
30. By checking this box, I certify, under the penalties of law, that the contents of this application to the best of my knowledge are accurate and complete.*

    1. I agree
32. Authorized Representative Name*
33. Authorized Representative's Title*
35. Date*
37. The permit process is not considered complete until this form AND payment are received.
    Please refer to the invoice for amount due.
39. Payment methods:
    Mail a check payable to City of Dubuque to:
    Water & Resource Recovery Center
    795 Julien Dubuque Dr.
    Dubuque, IA 52003
    OR
    Pay by credit card by calling 563-589-4176
40. Your permit will be mailed to your establishment once this form and payment are processed.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field