Food Establishment Permit Application

Food Establishment Permit Application
Establishment Name
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the mailing address the same as the street address?
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

Does the establishment cater?
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

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
Should be Empty:

Food Establishment Permit Application

Select Permit Category*

Credit Card

Select Permit Category