Food Establishment Application
Establishment Name
*
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the mailing address the same as the street address?
*
Yes
No
Mailing address (if different than street address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Establishment Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Name of Legal Owner
*
First Name
Last Name
Is the Legal Owner a:
*
Please Select
Individual
Partnership
Corporation
Association
Other
If Other, Please Specify:
*
Provide the name of all individuals comprising legal ownership and their mailing addresses
*
Certified Food Safety Manager's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Name of person applying for permit
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to the Business
*
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Does the establishment cater?
*
Yes
No
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?
*
Select Permit Category
*
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( X )
Catering Fee
If yes, you must give advanced notice to TriCounty Health Department for each catered event.
$
200.00
Quantity
1
2
3
4
5
6
7
8
9
10
Category 1
Serving only. No time/temperature controlled items.
$
300.00
Quantity
1
2
3
4
5
6
7
8
9
10
Category 2
Serving less than 5 time/temperature controlled items.
$
400.00
Quantity
1
2
3
4
5
6
7
8
9
10
Category 3
Cooking raw foods or serving more than 5 time/temperature controlled items. Certified Food Safety Manager required.
$
500.00
Quantity
1
2
3
4
5
6
7
8
9
10
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
Quantity
1
2
3
4
5
6
7
8
9
10
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.
*
Submit
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