Cherokee County Health Department Daycare Permit, Renewal, or Inspection Fee Application

Cherokee County Health Department
Daycare Permit, Renewal, or Inspection Fee Application

www.cchdtexas.org

Return both the completed application and fee made payable to the Cherokee County Health Department.
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 daycares; upon change of ownership or address of a daycare.
Renewals are due by January 1st of each year.

For assistance in completing this application, call (903) 683-2990

PURPOSE OF THIS APPLICATION:

[ ] New Daycare – Give start date: __________ [ ] Renewal [ ] Change of Ownership, Effective date: __________

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

DAYCARE INFORMATION:
1. Name under which Daycare is operated (DBA):_________________________________________________________________________ 2. Physical Address of Daycare: ______________________________________________________________________________________ Address Street, for Route – GIVE DIRECTIONS ON REVERSE City Daycare Phone # 3. Daycare Contact Person: _________________________________________________________Title:_____________________________ 4. Email Address: __________________________________________________________________________________________________ 5. Daycare Information: ____________m. to ____________m.______________________________________________________________ Opening Hours - Closing Hours of Operations Days of the week daycare will be open Total # of Workers 6. Daycare 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): Indicate Amount Paid 1. Daycare Centers

	[ ] 5 or less employees….………………………………………….............................	FEE DUE:	$50.00	_______
	[ ] 6 - 10 employees….………………………………………….................................	FEE DUE:	$100.00	_______
	[ ] more than 10 employees….…………………………………………......................	FEE DUE:	$150.00	_______
2.	Pre-Operational Inspection Fee for New Day Care Daycare or
	Re- opening Inspection Fee of Existing Location……………………………………..	FEE DUE:	$50.00	_______

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

4.	If your daycare 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 State licensing entity. …………………..	FEE DUE:	$50.00	_______

TOTAL FEES PAID:…………..…………………………………………………………..…………...

_______


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

(Daycare Application Form 05/08)

PURPOSE OF THIS APPLICATION:

DAYCARE INFORMATION:

1. Name under which Daycare is operated (DBA):_________________________________________________________________________

2. Physical Address of Daycare: ______________________________________________________________________________________

Address Street, for Route – GIVE DIRECTIONS ON REVERSE City Daycare Phone #

3. Daycare Contact Person: _____________________________Title:_

4. Email Address: __________________________________________________________________________________________________

5. Daycare Information: m. to m.__________________________________________________

Opening Hours - Closing Hours of Operations Days of the week daycare will be open Total # of Workers

6. Daycare 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): Indicate Amount Paid

1. Daycare Centers

If your daycare is a Non-Profit entity based on Internal Revenue Code, please

submit a copy of your documentation. Permit fees are exempted but an inspection

PURPOSE OF THIS APPLICATION:

DAYCARE INFORMATION:

1. Name under which Daycare is operated (DBA):_________________________________________________________________________

2. Physical Address of Daycare: ______________________________________________________________________________________

Address Street, for Route – GIVE DIRECTIONS ON REVERSE City Daycare Phone #

3. Daycare Contact Person: _________________________________________________________Title:_____________________________

4. Email Address: __________________________________________________________________________________________________

5. Daycare Information: ____________m. to ____________m.______________________________________________________________

Opening Hours - Closing Hours of Operations Days of the week daycare will be open Total # of Workers

6. Daycare 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): Indicate Amount Paid

1. Daycare Centers

If your daycare is a Non-Profit entity based on Internal Revenue Code, please

submit a copy of your documentation. Permit fees are exempted but an inspection

3. Daycare Contact Person: _____________________________Title:_

5. Daycare Information: m. to m.__________________________________________________

7. Owner’s Name: _______________________________________Phone #: