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2. Elderly Nutrition Program provider application
   Business interested in providing Elderly Nutrition Program services for Bayfield County residents should complete and submit this survey. Make sure to answer all questions/provide all requested documents. When completed, please press the Submit button, or if you prefer, print it out and mail to BCDHS, Attn: ENP partnership application, PO Box 100, Washburn, WI 54891.
4. 1. What is the name and address of your business?
6. Business Name
8. Address1
10. City
11. State
13. Zip
15. 2. Contact information of the owner/manager:
17. First Name
18. Last Name
20. Email Address
22. Phone Number
24. 3. Please upload a copy of your current license or certification
26. 4. Have you had any health code violations in the last 3 years?

    1. No
    2. Yes-describe violation below
28. Health code violation description
30. 5. What capacity do you have to prepare meals for this program? Please provide a minimum number of meals if required, a maximum number of meals that can be provided, how many days per week meals can be provided, and/or if meals can be provided all year or only part of the year. Please be as specific as possible.
32. 6a. Do you currently have the staff capacity to prepare meals for this program?

    1. No-answer 6b. below
    2. Yes
34. 6b. How long would it take to begin to provide meals?
36. 7. Do you have the capacity to provide take-out meals from your location for this program?

    1. No
    2. Yes
38. 8. Do you have the capacity to deliver meals from your location?

    1. No
    2. Yes
40. 9. Do you have an invoicing system that can break down raw food costs?

    1. No
    2. Yes
42. 10. After reviewing the dietary criteria below, please upload a minimum of 5-day sample menu
44. 
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field