Environmental Health

Please only click submit once Any information you provide on this form may be subject to disclosure under Wisconsin’s Public Records laws, in accordance with Wis. Stats. §§ 19.31-19.39.
Licensing Period:	July 1st, 2021 - June 30th, 2022
Application Date:	[None]

Please submit application and payment to:	Payment due with application:

City of Racine Public Health Department City Hall 730 Washington Avenue Room 1 Racine, WI 53403 Phone: (262) 636-9203 Fax: (262) 636-9165	Application and Inspection fee:	$390.00
	(Includes Building, Fire, and Health Inspection)
	Annual Permit Fee (State Mandated):	$210.00
	Room Tax Permit Fee:	$3.00
	Total Due:	$603.00
WI Seller's Permit Fee ($20) due to WI Department of Revenue in addition to above fees.
Application and payment may be made in office, through the mail, by fax, (application only) online, or (payment only) over the phone. Make Checks payable to: City of Racine
Note: Permits will not be processed until proper fees are submitted.
Property Address:

Property Owner Information
Name:
Address:
City:	State: Zipcode:
Phone:
Email:

Responsible Agent / Management Company (In Owner's Absence)
Name
Phone:
Email:

Property Information
Number of Rooms/Units for Rent:
Estimated Square Footage of Space for Rent
Zoning:

State of Wisconsin Department of Revenue Seller's Permit
Name on Permit:
Permit Number:
Address
City:	State: Zip: