Cherokee County Health Department

Temporary Food Establishment Permit Application

www.cchdtexas.org

Return both the completed application, and non-refundable 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.  For assistance in completing this application, call (903) 683-4688.

This application must be received by the Department at least 10 days prior to the event.

   Name under which Business is operated (D/B/A):___________________________________________________________________________
 

   Name of Owner: ______________________________________________________________________________________________________

   Address of Responsible Owner:_________________________________________________________________________________________
                                                              Mailing Address                                             City and State                                                 Zip Code

   Telephone Number of Owner: ____________________________ Owner’s Email Address: __________________________________________
 

   Event Contact Person and Phone Number: ________________________________________________________________________________
                                                                                                      Name Area Code and Phone Number

   Name Of Single Event or Celebration:_____________________________________________________________________________________

   Event Address:_______________________________________________________________________________________________________
                                                            Address                                            City                                                                               Zip Code

   Event Start Date: _________________________ Event End Date: ___________________________ Time: ______________________________

   Sponsor/Coordinator of Single Event or Celebration: ________________________________________________________________________

   Sponsor/Coordinator Address:___________________________________________________________________________________________
                                                                                    Address                                       City                                                             Zip Code

   Event Contact Person and Phone Number:_________________________________________________________________________________
                                                                                                   Name                                                             Area Code and Phone Number

   List Foods to be Prepared:______________________________________________________________________________________________

   Food Preparation address and/or service area:_____________________________________________________________________________
                                                                                               Address                                       City                                                  Zip Code

   □    Temporary Food Establishment Permit Single Event (Non-refundable) ---------------------------$25.00 per event

         Permit is valid for 14 consecutive days from the initial effective date.          (Per individual food booth/unit)
 

   □    Multi-Events Temporary Food Establishment Permit (Non-refundable) ---------------------------$100.00 annually

         Permit is valid for 14 consecutive days from the initial effective date. (Per individual food booth/unit)

   Exemption – Nonprofit as a 501 ( C ) Organization. You must possess a 501 ( C ) exemption under the Internal

   Revenue Code, or be a religious organization meeting the definition of a church under the Internal Revenue Code,

   ‘170(b)(1)(A)(I).

   □ Nonprofit 50l ( C) organization or religious organization

Title

Date

(Temporary Permit Application 5/08)