2. FOOD ESTABLISHMENT PERMIT APPLICATION
4. Today's Date*
7. A copy of the applicant's or applicant's agents driver license AND a copy of a VALID Food Protection Manager's Certificate is required.
9. FOOD ESTABLISHMENT INFORMATION
11. Type of Establishment (Select one only)*
    -- Select One --RestaurantBakeryDay CareRetailSandwich/DeliGrocery StoreCoffee ShopMobile UnitOther
13. Name of Establishment*
15. Establishment Address*
17. Bartonville, TX 76226
19. Manager of Establishment*
21. Manager's Phone Number*
22. Manager's Email Address
24. OWNERSHIP INFORMATION
26. Type of Ownership
    -- Select One --ProprietorshipCorporation (list registered agent in Texas)Partnership
28. Name of Proprietorship, Corporation, or Partnership*
30. Mailing Address (Street, State, Zip)*
32. Mailing address for renewal, permit mailing, and information if different from above (Street, State, Zip):
34. Name of Contact Person
35. Title
37. Contact Phone Number*
38. Contact Email
40. Upload Driver License*
42. Upload CURRENT Food Protection Manager's Certificate *
44. Mobile Food Units:

    An application for a permit for a mobile unit which operates from a fixed food facility, or commissary, located outside the town, shall include with the completed application a copy of the facility's current valid state and/or local health permit.

46. Mobile Units ONLY: Upload Copy of Current State/Local Health Permit
48. ELECTRONIC SIGNATURE & UNDERSTANDING OF RESPONSIBILITY*

    By checking “I agree” I understand any permit granted from this application may be revoked for cause.  Failure to comply with the Town of Bartonville Ordinances, rules and regulations, as well as any notices for correction of violations affecting public health and sanitation, and/or any false or misleading information provided on this application, shall be deemed cause for revocation of the Food Establishment Permit and CLOSURE of the establishment.

    I also agree and acknowledge my electronic signature is valid and binding in the same force and effect as a handwritten signature.

    1. I Agree
50. APPLICANT ELECTRONIC SIGNATURE*
52. After submission and your application is processed you'll be sent an email with a link to pay your application fee (if applicable).
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field