Fillable Environmental Health Department FOOD ESTABLISHMENT PERMIT APPLICATION (City of Coppell)

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Environmental Health Department FOOD ESTABLISHMENT PERMIT APPLICATION (City of Coppell)

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The Environmental Health Department FOOD ESTABLISHMENT PERMIT APPLICATION (City of Coppell) form is 1 page long and contains:

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City of Coppell
Environmental Health Department
FOOD ESTABLISHMENT PERMIT APPLICATION
P.O. Box 9478, Coppell, Texas 75019-4409 (972) 462-5177 or 5164
PERMIT STATUS: (Check One) New Business _______ Renewal _______ Change Of Owner ________
BUSINESS NAME:_________________________________________________________
_
_______________________
PHYSICAL ADDRESS:
(STREET NO. & NAME) (CITY, STATE) (ZIP CODE)
BUSINESS PHONE:_______________________________ EMAIL:_________________________________________
AFTER HOURS EMERGENCY CONTACT / PHONE # _____________________________________________________
NAME OF OWNER:________________________________________________ PHONE: ________________________
MAILING ADDRESS:
(STREET NO. & NAME) (CITY, STATE) (ZIP CODE)
HOURS & DAYS OF OPERATION:
(INCLUDE THE HOURS PERSONNEL ARRIVE AND LEAVE THE ESTABLISHMENT)
_____________________________________________________________________________________________________________________________________________________
I attest that the information provided above is true and accurate. I agree to comply with the City of Coppell rules and
regulations and understand that failure to do so may result in revocation or suspension of the permit.
The permit is effective for one year from the date of issuance unless sooner revoked for a cause.
The permit is not transferable and the permit fees are non-refundable.
____________________________________________ _______________________________
Signature of Applicant Date
Submit application and fee to City of Coppell, Environmental Health, P.O. Box 9478, Coppell, Texas 75019
Office Use Only
FEE SCHEDULE:
Grocery Store $150.00 per department Low Priority Food Establishment $250.00
High Priority Food establishment $400.00 Plan Review $100.00
Medium Priority Food Establishment $300.00
Approved By ____________________________________________________ Date of Approval__________________
Receipt No. __________Check # ____________Amount $ ___________ Received By ___________Date_____________
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Environmental Health Department FOOD ESTABLISHMENT PERMIT APPLICATION (City of Coppell)

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Completed 2 August 2020

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