Coordinator Application for Single Event Or Celebration

RUSK COUNTY HEALTH DEPARTMENT

115 N. Main St. • Suite 500A • Henderson, Texas 75652 • (903) 657- 3832

COORDINATOR APPLICATION FOR “SINGLE EVENT OR CELEBRATION”

A “single event or celebration” occurs at one location once a month or less frequently. Events or activities that occur daily, weekly, or more frequently than once a month at a location are considered continuous operations and do not constitute a “single event or celebration”. A Temporary Food Establishment may operate only in conjunction with a “single event or celebration” at a fixed location for a period of time not to exceed fourteen (14) consecutive days. The coordinator of the event is responsible for crowd control, trash control, and connection to utilities, toilet facilities and traffic control. Coordinator Applications should be submitted 30 days prior to a “single event or celebration.” Texas Health & Safety Code Chapters 437 and 121; Rusk County Health Department Order # 2009-02-02CC

COORDINATOR / EVENT INFORMATION Date of Single Event/Celebration: Start Date:______End Date:______Start

Time:______Name of Single

Event/Celebration:______

Address of Single

Event/Celebration:______City:______Zip:______

Coordinator of Single

Event/Celebration:______Phone:______

Coordinator Mailing

Address:______City:______St:______Zip______

Person In Charge on-site at the Single

Event/Celebration:______Cell:______

NAME(S) OF TEMPORARY FOOD ESTABLISHMENT(S) PROPOSED Each proposed Temporary Food Establishment must submit completed application and permit fee to the Rusk County Health Department at least 10 days prior to the event or be subject to a $50.00 administrative fee. Applications must match list provided below. A separate form is required for additional vendors. Name of Establishment/Contact Person Phone # Name of Establishment/Contact Person Phone #

1)______6)______

______2)______7)______

______

3)______8)______

______

4)______9)______

______

5)______10)______

______

FEE INFORMATION (Payment can NOT be made at the event site) [ ] Single Event or Celebration (Non-refundable) ------$25.00 per event [ ] Nonprofit 50l (C) organization or religious organization------Exempt Fee Exemption – Nonprofit as a 501(C) Organization. You must possess a 501(C) exemption under the Internal Revenue Code, or be a religious organization meeting the definition of a church under the Internal Revenue Code, 170(b)(1)(A)(I). APPLICATION MUST BE FILLED OUT COMPLETELY. FAILURE TO PROVIDE ALL INFORMATION WILL DELAY PERMIT. I attest that the information above is true and accurate. I fully understand that any deviation from the above without prior permission from the Rusk County Health Department may nullify approval. Approval by the Rusk County Health Department does not indicate compliance with any other code, law or regulation that may be required (i.e., federal, state or local). As an applicant, I agree that the Rusk County Health Department, its officers and employees are indemnified against all claims of injury, damage to persons or property, whether public or private, arising out of “A Single Event or Celebration” or the “Temporary Food Establishment” operating in conjunction with a “Single Event or Celebration”.

______Applicant Signature Printed Name of Applicant Date

OFFICE USE ONLY Date Received:______Check/MO/Receipt #:______Fee Paid: $______