Food Establishment Application Permit,Renewal, Inspection Application Fee

For assistance in completing this application, call (903) 683-4688.

PURPOSE OF THIS APPLICATION:

[ ] New Business – Give start date: ______________ [ ] Renewal [ ] Change of Ownership, Effective date: ____________

[ ] Amended – Specify type of change [ ] Change of Business Name, or [ ] Change of Physical Location, Effective date: ____________

FOOD ESTABLISHMENT INFORMATION:

1. Name Under Which Food Establishment is operated (DBA):

________________________________________________

2. Physical Address of Food Establishment:	________________________________________________________________
	Address Street, For Route–GIVE DIRECTIONS ON REVERSE City Establishment Phone #

3. Food Establishment Contact Person:

____________________________________________

Title:

_________________


4. Email Address For Contact Person:	___________________________________________________________________

5. Food Establishment Information:	______m.	to _________m.	_____________________________	______________
Opening Hours	- Closing	Hours of Operations	Days of the week establishment will be open	Total#of Workers

6. Mailing Address (if different):	_______________________________	___________________	____________	_______
	Address	City	State	Zip

7. Owner’s Name:

________________________________________________________

Phone #:

__________________

8. For Corporations, President or Chief Officer’s Name & Title:

_______________________________________________

FEE INFORMATION: (Please check appropriate box (es):

1. [ ] Food Establishment [ ] Caterer located in Cherokee County [ ] Convenience Store [ ] Package Store

Indicate Amount Paid

[ ] 5 or less employees….………………………………………….....................	FEE DUE:	$50.00	_______
[ ] 6 - 10 employees….………………………………………….........................	FEE DUE:	$100.00	_______
[ ] 11 - 25 employees….………………………………………….........................	FEE DUE:	$150.00	_______
[ ] 26 - 35 employees….………………………………………….........................	FEE DUE:	$200.00	_______
[ ] 36 - 50 employees….………………………………………….........................	FEE DUE:	$250.00	_______
[ ] more than 50 employees….…………………………………………................	FEE DUE:	$300.00	_______

2.	Pre-Operational Inspection Fee for New Food Establishment or Re-opening Inspection Fee of Previously Existing Location……..…………………......	FEE DUE:	$50.00	_______

3.	[ ] Nursing Home or [ ] College with food service provided by college......................	FEE DUE:	$75.00	_______

4.	[ ] Hospital…………………………………………………..……..………………………	FEE DUE:	$200.00	_______

5.	[ ] Out of county caterers who sell only commercially pre-packed foods……………	FEE DUE:	$200.00	_______

6.	[ ] Out of county caterers who prepare foods………………………..….……………….	FEE DUE:	$300.00	_______

7.	Administrative late fee due if renewal application not remitted by January 31^st	FEE DUE:	$50.00	_______

8.	Non-profit establishment required by a State licensing entity to have local inspection..	FEE DUE:	$50.00	_______
	TOTAL FEES PAID			_______

If your business is a Non-Profit entity based on Internal Revenue Code, please submit a copy of your documentation. Permit fees are exempted but an inspection fee is due per inspection required by your licensing entity.

I certify that the information furnished is true and correct to the best of my knowledge.


Printed Name of Applicant		Title


Signature of Applicant		Date
		(Food Establishment Application Form 5/08)

Cherokee County Health Department

Application for Permit, Renewal Permit, Inspection Application Fee

www.cchdtexas.org

FOOD ESTABLISHMENT INFORMATION:

FEE INFORMATION: (Please check appropriate box (es):