Food Establishment Permit Application

Food Establishment Permit Application
Establishment Name*
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Mailing address (if different than street address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Establishment Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

Name of Legal Owner*

First NameLast Name
Is the Legal Owner a:*
If Other, Please Specify:*
Provide the name of all individuals comprising legal ownership and their mailing addresses*
Certified Food Safety Manager's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of person applying for permit*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to the Business *

YesNo
Days and Hours of Operation:*
Ex) M-F 9 a.m. - 5 p.m., Sat-Sun 8 a.m. - 12 p.m.
If non-continuous, Opening and Closing Date:
Ex) 1/21/2026 to 2/21/2026, 10 a.m. - 4 p.m.
What Entity Issued your Business License?*
Who provides your public water and sewer connection?*
Please note that any permits that are renewed after March 1, 2026 are subject to a late fee 50% of the original permit cost.

Please call TriCounty Health to pay any late fees once the application has been submitted.

Select Permit Category*

Catering Fee

If yes, you must give advanced notice to TriCounty Health Department for each catered event.

$200.00

Category 1

Serving only. No time/temperature controlled items.

$300.00

Category 2

Serving less than 5 time/temperature controlled items.

$400.00

Category 3

Cooking raw foods or serving more than 5 time/temperature controlled items. Certified Food Safety Manager required.

$500.00

Category 4

Establishments that are high risk based on history and past violations. Please call TriCounty health to determine if your establishment falls under this category.

$600.00

Total

$0.00

Credit Card

I hereby certify to the best of my knowledge, the foregoing information is correct. I agree to abide by TriCounty Health Department’s food establishment sanitation rules. I understand that this permit is revocable for non-compliance with health department rules and regulations. The health department will be allowed inspection access to the establishment and establishment records. I understand that this permit is non-transferable.*

Clear
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