Cherokee County Health Department

Application for Mobile Unit Permit or Renewal Permit

www.cchdtexas.org

Return both the completed application and fee made payable to the Cherokee County Health Department and mail to:  593 North Main Street,  Rusk, Texas 75785.  FAILURE TO PROVIDE ALL INFORMATION REQUIRED WILL DELAY PERMIT.    Due Date:  Before beginning operations for new businesses; upon change of ownership or address of a business; Renewals are due by December 31st of each year.

 

 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 Mobile Unit is operated (DBA): _______________________________________________________

 

2. Physical Address of Mobile: _______________________________________________________________________
  Address Street, For Route–GIVE DIRECTIONS ON REVERSE                          City                      Zip
3. Business Contact Person: ____________________________________________

Title:

 ___________________
   
4. Email Address For Contact Person: ___________________________________________________________________
       
5. Telephone Number at Address: (      )_________________

Cell Number on mobile unit:

 (        )________________
       
6. Operating Information:

___________m.

 to ________________m. ______________________________

  

Opening Hours -

 Closing Hours of Operations   Days of the week mobile unit will be open

 

7. Mailing Address (if different):

 _____________________________

  ___________________ ____________  ________
  Address City    State  Zip

 

8. Owner’s Name: ________________________________________________________ Phone #: ____________________

 

9. Location (s) where you plan to operate mobile unit: __________________________________________________

 FEE INFORMATION:  Mobile Food Unit - a vehicle-mounted mobile food establishment designed to be readily moveable.  

**A PRE-OPERATIONAL INSPECTION MUST BE PERFORMED AFTER PAYMENT AND PRIOR TO PERMIT ISSUANCE AND OPERATING.**

 Indicate Amount Paid
1. Push Cart (Per Unit)....................................................................................... FEE DUE:

$50.00

  _________
         
2. Mobile Food Unit (Per Unit)……………………………………………..……..…… FEE DUE:

$100.00

 _________
         

3.

 

Pre-Operational Inspection Fee for New Mobile Unit or

Re- opening Inspection Fee of Existing Unit..................................………….

  

FEE DUE:

 

$50.00

 

 _________
         
4. Administrative fee due for renewal application postmarked after December 31st
or operating without a valid permit		 FEE DUE:

$50.00

 _________
         
5. 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.  
 

Type of Unit:     (  )  Truck     (  )  Van     (  )  Trailer     (  )  Pushcart     (  )  Other

Vehicle Identification/Serial No._______________________________________

 

Unit No. and/or Truck No.  ___________________________________________

 

License Plate No./State  ____________________________________________

Description of Vehicle

 

Make:  ___________________ Model:  ___________________

 

Year:  __________  Size:  __________  Color:  ____________

 

 List Foods to be Sold:_________________________________________________________________________
 
 Commissary Address, City/State, Zip: ___________________________________________________________
 
  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
   

(Mobile Unit Form 11/09)
 

APPLICATION AFFIDAVIT 

I, _______________________________________________________,
                                             (printed name)
 
understand that the permit only gives me permission to operate the mobile food unit. If another person takes responsibility for the mobile unit, I understand that they cannot use my permit. They must apply for their own permit.

I also understand that the permit to be issued contains a statement at the bottom of the document which states the permit cannot be moved to another location and that another person cannot use the permit.


Signed:  _________________________________________________
 

Date:  ___________________________________________________