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Application for Temporary Health Permit

2. 
3. Gillespie County Health Division
   126 West Main Street, Fredericksburg, TX 78624 / Phone: 830-997-7521 / Fax: 830-997-1861 / E-mail: kolfers@fbgtx.org
7. NO HOME PREPARED FOODS ALLOWED
9. Vendor Name:*
11. Representative/Owner First Name*
12. Representative/Owner Last Name*
14. Mailing Address:*
16. City*
17. State*
18. Zip*
20. Phone #:*
21. E-mail address:
23. Event:*
    Enter the name of the event
24. Event Location:*
    Enter the address, including city and zip of the event location.
26. Date & Time of Event:*
    Date & Time of Event: Start Date

    Date & Time of Event: Start Time

    —

    Date & Time of Event: End Date

    Date & Time of Event: End Time
    Application is due no later than 10 days before the event.
27. Multi-Day Event:
    If the event is more than one day, type in the additional dates and times above.
29. Types of food sold/given away:*
31. The food will be obtained from the following approved sources:*

    Please check both if they apply. For vendors that purchase food from a permitted facility, vendor agrees to maintain their receipts from the purchase on-site at the event for verification. For questions about how to answer this section, please call 830-990-2027.

    1. I operate from/own a permitted food facility (such as a restaurant)

    1. I will purchase food from a permitted food facility (such as a grocery store or restaurant) on the day of the event and bring the food directly to the event.
33. If you selected "I operate from/own a permitted food facility" above, please complete the section below. Otherwise skip to the next section:
35. Food Facility Name:
36. Permit Number:
38. Food Facility Address:
40. City:
41. State:
42. Zip:
44. If you selected "I will purchase food from a permitted food facility" above, please complete the section below:
    Please note that the section below, the section above, or both (if applicable), must be completed in order for the application to be complete.
46. Food Facility Name:
47. Phone Number:
49. Food Facility Address:
51. City:
52. State:
53. Zip:
57. Recognized as a Non-Profit [501(c)(3)] Organization?*
    -- Select One --YesNo

    *No fee due for Non-Profit [501(c)(3)] Organizations
58. Application type:*

    Please check all that apply.

    1. $50.00 Per Event (Valid for up to 14 days)
    2. $110.00 Per Year (Valid January 1 through December 31)
    3. $20.00 Late Fee (Applicable when making application fewer than 10 days before the event)
60. Payment options:*

    Please select how you will pay for your permit. Checks should be made payable to the "City of Fredericksburg." Mailing address: 126 W. Main St., Fredericksburg, TX 78624. Payment accepted: cash, check, credit card.

    1. I will mail a check
    2. I will bring payment to you in-person at the office
    3. I will call the office at 830-990-2027 to take a credit card over the phone
61. Food Handlers Certificate:
    Upload a valid Food Handlers certificate for an employee that will be on-site. This is not required for non-TCS foods (Time and Temperature Control for Safety).
63. Food Manufacturer Permit, when applicable:
    Upload your food manufacturer permit.
64. Temporary Health Permit Inspection Checklist:
    Temporary Health Permit Inspection Checklist

    The link to this checklist provides a list of requirements necessary for the approval of a Temporary Food Establishment operating within the jurisdiction of the Gillespie County Health Division. Temporary food establishment equipment and criteria may vary depending on the type of operation. Refer to the Texas Goof Establishment Rules (TFER) for complete information regarding the requirements.
66. Special Requests or Notes:
    If you need to make a special request or inform us about an item on this application, please let us know using the text box above.
70. Application Submittal:
    In making application for a Temporary Health Permit, which is necessary to operate my business or organization, I understand and agree to comply with all Gillespie County Health Division city ordinances, county orders, and state laws that may govern the conduct or operation of my business.
72. Owner/Representative Name:*
73. Last Name*
75. Date:*
    Date:
    Enter today's date.
79. FOR OFFICE USE ONLY:
    Gillespie County Health Division Use Only; applicants please leave the sections below blank other than filling in your email address in order to receive a copy of your application. Thank you!
81. Permit No.:
82. Date Permit Released:
84. Payment Form:
85. Amount Due: $
86. Late Fee:
Leave This Blank:


88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit

* indicates a required field