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Richardson Food Service License

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					                       CITY OF RICHARDSON HEALTH DEPARTMENT
                       FOOD SERVICE PERMIT APPLICATION
                     P.O. Box 830309, Richardson, Texas 75083-0309  (972) 744-4080

                                       (TYPE OR PRINT ALL INFORMATION)



TODAYS DATE:___________________________                         OPENING DATE:_______________________________
                                                                                        (FOR NEW CONSTRUCTION/NEW OWNER/REMODEL)


ESTABLISHMENT NAME:_________________________________________________________________________

ESTABLISHMENT ADDRESS: _____________________________________________________________________
                                    (STREET NO. & NAME)                                                                   (ZIP CODE)



MAILING ADDRESS: _____________________________________________________________________________
                     (STREET NO. & NAME/P.O. BOX)                                   (CITY, STATE AND ZIP CODE)



ESTABLISHMENT PHONE: ____________________________ ALT PHONE: _______________________________

TYPE OF CUISINE: ______________________________________________________________________________

ESTABLISHMENT WEBSITE: ______________________________________________________________________

EMAIL ADDRESS: _______________________________________________________________________________

TOTAL NUMBER OF EMPLOYEES:                                            WILL YOU BE CATERING?                      YES          NO

TOTAL SQUARE FOOTAGE OF FOOD SERVICE ESTABLISHMENT ______________________________________
                                                                              (INCLUDE ALL PREPARATION, STORAGE, AND DINING AREAS)


OWNER’S NAME: _______________________________________________________________________________
                          (PLEASE PRINT CLEARLY, THIS WILL APPEAR ON THE HEALTH PERMIT CERTIFICATE)


APPLICANT'S NAME_____________________________________________________________________________

APPLICANT’S SIGNATURE: _______________________________________________________________________

                              ** PLEASE DO NOT WRITE BELOW THIS LINE **

FEE: ________________________                             FOOD ESTABLISHMENT PERMIT FEE:
                                                            0-2,000 square feet .........................................$250.00
                                                            2,001-7,500 sq. ft. ...........................................$350.00
APPROVED BY:                                                Over 7,500 sq. ft..............................................$450.00
               HEALTH AUTHORITY
                                                          Commercial Daycare Permit Fee .........................$100.00

                                                          New Establishment Plan Review Fee ..................$100.00
                                                          New Establishment/Change of Owner Fee............$50.00

COMMENTS: ___________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

NOTE: EXPIRATION OF HEALTH PERMIT WILL RESULT IN IMMEDIATE CLOSURE OF ESTABLISHMENT.

				
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