Fillable FOOD ESTABLISHMENT PERMIT APPLICATION (City of Alamo Heights)

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FOOD ESTABLISHMENT PERMIT APPLICATION (City of Alamo Heights)

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BROWSE CITY OF ALAMO HEIGHTS (TX) FORMS

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CITY OF ALAMO HEIGHTS
COMMUNITY DEVELOPMENT SERVICES DEPARTMENT
6116 BROADWAY SAN ANTONIO, TEXAS 78209
(210) 826 – 0516 (210) 832 – 2299 [FAX]
FOOD ESTABLISHMENT PERMIT APPLICATION
Return both the completed application and non-refundable fee (made payable to the CITY OF ALAMO HEIGHTS)
or mail to the address noted above.
TYPE OF APPLICATION: RETAIL CHILDCARE SCHOOL
TEMPORARY [14 DAYS] APPLICATION DATE: _____________
Name Under Which Business is Conducted (DBA): ______________________________________________
Physical Address to be Licensed: _____________________________________________________________
City, County, State, Zip Code: __SAN ANTONIO, BEXAR, TEXAS 78209__
Telephone # at address: ( 210 ) _____________________
FEE SCHEDULE (§8-34, Ordinance 1517, & Ordinance 1570, Alamo Heights City Code)
Fees for food service establishments are based on the total number of employees which may come into contact
with food. This includes wait staff, servers, and cooks but does not include hosts, hostesses, valets, or
business employees. Mark the appropriate category and remit fee accordingly.
1 – 3 employees $100.00 11 – 20 employees $400.00
4 – 6 employees $200.00 over 20 employees $500.00
7 – 10 employees $300.00 Fees are non-refundable
Food Establishment - any place where food is prepared and intended for individual portion service. This includes
the site at which individual portions are provided for consumption on or off the premises and regardless of
whether there is a charge for the food, bed & breakfasts with >7 rooms, restaurants, bars, cafes, snack bars,
hospitals that serve food to the general public, correctional facilities & jails that contract with professional food
management corporations for food preparation, privately-owned correctional facilities, etc.
VERIFICATION: I SWEAR OR AFFIRM THAT ALL INFORMATION IN THIS APPLICATION IS TRUE AND CORRECT. I FURTHER
CERTIFY BY SIGNATURE HEREON THAT I AM AUTHORIZED TO EXECUTE THIS DOCUMENT ON BEHALF OF
THE CORPORATION. I AM NOT CURRENTLY DELINQUENT IN THE PAYMENT OF ANY CORPORATION
FRANCHISE TAXES OWED THE STATE OF TEXAS UNDER CHAPTER 171, TAX CODE, NOR AM I DELIQUENT IN
THE PAYMENT OF ANY FEES AND TAXES OWED THE CITY OF ALAMO HEIGHTS. IF SIGNING THIS AS OWNER
OF A SOLE PROPRIETORSHIP, I AM NOT DELINQUENT IN THE PAYMENT OF ANY CHILD SUPPORT OWED
UNDER CHAPTER 232, FAMILY CODE. IF SIGNING AS A SOLE PROPRIETOR, I CERTIFY I HAVE FILED THE
ASSUMED NAME CERTIFICATE IN APPROPRIATE COUNTIES PURSUANT TO BUSINESS AND COMMERCE
CODE, CHAPTER 36. I FURTHER CERTIFY THAT I HAVE READ AND UNDERSTOOD CHAPTER 437 OF THE
TEXAS STATE HEALTH & SAFETY CODE, THE APPLICABLE PROVISIONS OF 25 TAC, CHAPTER 229, AND THE
APPROPRIATE PROVISIONS OF THE ORDINANCES AND CODES OF THE CITY OF ALAMO HEIGHTS, AND THAT
I AGREE TO ABIDE BY THEM.
__________________________________ OWNER PARTNER
Signature CORPORATE DESIGNEE/AGENT
_______________________________ PRESIDENT OTHER: ____________
Printed Name & Title
click to sign
signature
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PURPOSE OF THIS APPLICATION:
[Mark appropriate box to indicate purpose of application, and/or any change in status of firm.]
New - Planned Start Date of Regulated Activity: _________________
Amended [indicate what amendment is needed] Indicate effective date: ________________
Change of Ownership [previous owner: ____________________________]
Change of Location [previous location: ____________________________]
Change of Name [previous name: _______________________________]
Other: ___________________________________________
Change of name, ownership, or change in the location of a licensed place of business, requires
submission of a new application and fee. The effective date of change becomes the new anniversary
date.
Renewal - Renewals are valid for one year from the anniversary date.
Notice that firm is out of business. Effective Date: _________________
Sign and date. Return for deletion from our records.
Not required to license/permit. Reason: ________________________________________
(Attach documentation)
RESPONSIBLE INDIVIDUAL IN CHARGE AT PHYSICAL ADDRESS
_______________________________________ __________________________________
Name & Title Food Handler Certificate Date and Number
BUSINESS HOURS OF OPERATION:
SUN _____ __.M. to _____ __. M. THURS _____ __.M. to _____ __. M.
MON _____ __.M. to _____ __. M. FRI _____ __.M. to _____ __. M.
TUES _____ __.M. to _____ __. M. SAT _____ __.M. to _____ __. M.
WEDS _____ __.M. to _____ __. M.
NOTE: PER CITY ORDINANCE, NO FOOD SERVICE BETWEEN 2 & 6 A.M., ANY DAY OF THE WEEK
BILLING INFORMATION (The license/permit and/or courtesy renewal notice will be sent to the following):
Billing Name: _______________________________________________________________________
Billing Address: _____________________________________________________________________
City, State, Zipcode: _________________________________________________________________
Name of Application Preparer (Contact Person): ___________________________________________
Telephone Number of Application Preparer (Contact Person): ________________________________
Fax Number of Application Preparer (Contact Person): ______________________________________
E-mail Address of Application Preparer (Contact Person): ____________________________________
[PREFERRED METHOD OF CONTACT TELEPHONE FAX EMAIL US MAIL]
LICENSE/PERMIT HOLDER INFORMATION: Complete the required ownership information. Include copies of proof of
Taxpayer ID#, Charter #, Business Status.
[Legal name of company must be identical to the name on your State Tax Payer's Identification on file with the
Texas Comptroller of Public Accounts.]
___________________________________ ______________________ _______
Name Tax Payer ID # or Charter # Outlet #
___________________________________ _________________________ _____________
Mailing Address of Licensed Establishment City and State Zip
* Has the applicant, licensee, and/or managing officer ever been convicted of a felony or misdemeanor?
Yes No (If yes, please attach a statement explaining the conviction.)
SOLE OWNER I PROPRIETORSHIP
____________________________ _______________________________________________________
Name Residence Address (include City, State, and Zip Code)
PARTNERSHIP LLP
____________________________________________________ _______________________
Name of Partnership Effective Date of Partnership
____________________________________ ________________________________________________
Name Residence Address (include City, State, and Zip Code)
____________________________________ ________________________________________________
Name Residence Address (include City, State, and Zip Code)
____________________________________ ________________________________________________
Name Residence Address (include City, State, and Zip Code)
ASSOCIATION
____________________________________ ________________________________________________
Name Residence Address (include City, State, and Zip Code)
____________________________________ ________________________________________________
Name Residence Address (include City, State, and Zip Code)
CORPORATION LLC
___________________________________________ __________________________________
Name of Corporation Date and Place of Incorporation
____________________________________ __________________________________________________
President’s Name Residence Address (include City, State, and Zip Code)
____________________________________ __________________________________________________
Name of Registered Agent Residence Address (include City, State, and Zip Code)
Phone Number of Registered Agent: (_____) _____________________
[FOR SPECIAL PURPOSE, NON-TEMPORARY PERMITS ONLY]
TYPE OF OPERATION
Child Care Center - a facility that is licensed by regulatory authority to receive 13 or more
children for care, that prepares food for on-site consumption.
School Food Establishment - operated on a for-profit basis by a private contractor.
List Foods To Be Sold: ______________________________________________________________
Commissary Name: ________________________________________________________________
Address, City/State, Zipcode: _________________________________________________________
Phone: __________________________ STATE RETAIL PERMIT #: _______________________
A separate license/permit is required for each location. All
licenses/permits shall be displayed at the address licensed/permitted.
The license/permit will be valid for one year from the new, renewal, or
change date.
The license/permit renewal application and fee are due each year
PRIOR TO the anniversary date. This office must be advised of any
changes of ownership, name, or address PRIOR TO the change, as this will
change the anniversary date.
Please note that it is the responsibility of the license / permit holder to
remit the renewal application and fee before the expiration date, whether a
payment notice is received or not.
This license / permit DOES NOT take the place of appropriately issued
Food Handler Certificates. Contact the St. Phillips College Office of
Continuing Education for more information and class schedules. Such
certificates are required for all forms of Food Establishment Permit issued
by the City of Alamo Heights.
All retail food establishments in Texas are required to obtain a retail
food establishment permit from the regulatory authority that has the
permitting and inspectional responsibility for the establishment.
This permit does not address alcohol-related licensing.
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FOOD ESTABLISHMENT PERMIT APPLICATION (City of Alamo Heights)

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Completed 22 January 2021

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