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.

 
Payment may NOT be made at the event site.

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: __________________________________________
 

   Vendor 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 (at Same Event Location) Temporary Food Establishment Permit (Non-refundable) ---------------------------$100.00 annually

                                                                                                                                                           (Per individual food booth/unit)


   Fee 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

  
     
    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
   

(Temporary Permit Application 11/09)