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2. COW
3. Date
   Date

5. Note: This application must be filled out completely. Incomplete applications will not be accepted. Applications for a permit to operate do not guarantee that a permit will be granted. Permit approval is based upon the establishment compliance with state, local health, and City regulations. 

7. Food Establishment Permit
   Food Establishment Permit
8. Price

   1. Annual Renewal - 150.00
   2. Annual Renewal - 250.00
   3. Annual Renewal - 350.00
   4. Pre-Operational Plan Review & (2) Inspections Fee (new business) - 350.00
   5. Change of Business Name - 75.00
   6. Change of Ownership - 75.00
   7. Change of Physical Location - 75.00
   8. Administrative Late Fee (assessed every 30-days past the due date) - 20.00
9. Quantity
10. Shipping Cost
12. Taxable
14. Purpose for Application

    1. Annual Renewal
    2. New Business
    3. Change of Business Name
    4. Change of Ownership
    5. Change of Physical Location
    6. Amendment- Specify Type of Change
15. Specify Type of Change
17. Effective
    Effective
18. Previously Known As
22. Food Establishment Information
24. Name of Food Establishment (DBA)
26. Physical Location
28. Establishment Phone Number
29. Contact Person
31. Email Address

    Future reminders will be emailed to address on file

33. Do you currently have a TABC License?

    1. Yes
    2. No
34. Operation Hours
36. Total Number of Workers
37. Days of the Week Establishment Will Be Open
39. Mailing Address (if different)
41. Owner's Name
42. Phone Number
44. For Corporations: President or Chief Officer’s Name & Title
46. If Changing Business Name, Ownership or Physical Location, Specify New Information
50. Establishment Fee Schedule
52. If Food Establishment:
54. Number of Employees
55. Fees

    1 to 15 employees: $150

    16 to 30 employees: $250

    31 or more employees: $350

56. Fee Total
58. If Child/Adult Care, Church and School Inspections:
60. Licensed Number of Children/Adults
61. Fees

    1 to 15 people: $150

    16 to 30 people: $250

    31 or more people: $350

62. Fee Total
64. Further Fees:
    • Change of Business Name, Ownership, or Physical Location Fee: $75
    • Pre-Operational Plan Review & Inspection Fees (new business): $350
    • Administrative Late Fee (If the form is not postmarked by January 31st): $20 late fee to be assessed every 30 days past the due date
66. Please Calculate Total Fees Due

68. I understand that the attached application is for permission to operate a food establishment within the City Limits of Wimberley and only at the location indicated on this application. I understand that the permit states at the bottom of the document that such permit cannot be moved to another location and that the permit is not transferable and cannot be used by anybody else other than the name of the establishment on this application. I understand that during the term of the permit to issued, I and my employees will allow the Environmental Health Inspector(s) designated by the City of Wimberley access to the premises during normal working hours to conduct such inspections as may be necessary to guarantee compliance with health codes. I specifically waive any right to demand the issuance of a search warrant or other investigative order prior to conducting such inspections. I certify that the information furnished on this application is true and correct to the best of my knowledge. 

    If your business is a non-profit entity based on Internal Revenue Code, please submit a copy of your documentation, along with this application. Permit fees for such entities are exempted; however, applicable inspection fees are due as required by the City of Wimberley and fee schedule above.

70. Owner/Applicant’s Name as Acknowledgement
71. Owner/Applicant's Title
72. Date
    Date
76. Forms of Payment

    Payments via phone with a credit card by calling 512-648-2404. Payment via Checks/Money Orders should be done using drop box, mail, or physical address. Payments via Cash should be exact change only.

78. Inspection Fee Schedule
    • 1 to 15 Employees: $150
    • 16 to 30 Employees: $250
    • 31 or More Employees: $350
    • Food Establishment Compliance Inspection (Inspection triggered by complaint): $75
    • Food Establishment Compliance Re-Inspection (Fee increases by $25 per inspection and is cumulative): $100
80. Child/Adult Care, Church & School Establishment Inspection Fee

    Licensed Number of Children	Fee without Food Preparation	Fee with Food Preparation
    13 to 40 Children	$75	$150
    41 to 100 Children	$150	$250
    101 or more Children	$250	$350

82. Child/Adult Care Sanitation Inspection

    (Includes facilities with fewer than 13 children/adults)

    • Annual Food Establishment Permit (Includes 2-inspections a year): $150 to $350
    • Mobile Food Unit: $75 for first unit
    • Temporary Structure: $25 per structure
    • Additional Mobile Food Units: $50 for each additional unit
    • Special Food Vendor: $25 per day, per event
    • Seasonal Special Food Vendor (valid for 6 months): $75
    • Market Days Seasonal Permit (Valid for 10 months): $100
    • Change of Business Name: $75
    • Change of Ownership: $75
    • Change of Physical Location: $75
    • Establishment Plan Review: $75
    • Plan Review and 2 Pre-Opening Inspections: $350
    • Each additional Pre-Opening inspection: $125
    • Annual Establishment and Inspection Late Fee (Fee for all establishments paid 30 days or more past the due date of January 31st): $20 for each 30 days past the due date
86. For Office Use Only
88. Application Received
89. Fees
90. Payment

    1. Cash
    2. Check
91. Check Number
93. Other Form of Payment
94. Verdict

    1. Permit Approved
    2. Permit has been denied (see following question)
    3. Incomplete Application (return to vendor)
96. Notes
98. Name of Environmental Health Inspector as Signature
99. Date
    Date
100. COW Number
Leave This Blank:


101. Calculate Totals Proceed to Checkout

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