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Plik <br /> -,. ;^ SNOHOMISH <br /> 4 HEALTH DISTRICT <br /> WWW.SNOHD.ORG <br /> Genera!F. -d Plan Review Application <br /> Application must be completed in full and submitted with fee and the items listed for processing: <br /> Reviewed by ENS Initials <br /> ❑ 00 (PE 5672) lus$185 per hour after 2 hours New food service establishment <br /> 185 Base fee plus$185 per hour for each add! Remodel of existing food service establishment or revision of approved <br /> Ihqur over 1 hour(PE 5685) . plan <br /> $335 Base fee plus$185 per hour for each add! Change of ownership/conditional operating permit AND remodel of <br /> hour(PE 5685&5642) existing food service establishment or revision of approved plan <br /> ❑ $185 (PE 5682)per inspection Reopen former food service establishment <br /> ❑ $185 (PE 5670) New Limited Grocery,Tap Room/Tasting Room <br /> ❑ $185 plus lab fees (PE 5683) HACCP-when required by WAC for menu items <br /> ❑ $500 Base fee plus$185 for each add] permit New multiple permit food service establishment(large grocery store) <br /> (PE 5676&5675) <br /> ❑ $185 (PE 5677) Plan review consultation (On and/or off site) <br /> ❑ NO FEE Out of County Mobile (PE56MR) Mobile o.erators from King or Pierce Counties <br /> �+ ,�gyypp}}#� ���7�n.C�RiGl�' ►� -. � 6. x 7r�c <br /> , <br /> Name: T 52"/",ii r`� , Name: <br /> Site Address: 11 .e.. , Mailin. Address: -Seili'i,. <br /> City 6fr-c,,..‘,(0-X7rZSate ZIP Y ( <br /> y/��II�� y'�(,�ry,4.y� YY3lIP cl � City: y. : k N;�. .,,; <br /> ,:.-2./ i g �l'a-�tAti .. ,. f . _ ��... - .. - .v L.:. ,. `{ti. -,v,.. 4<�Z. hz ..T <br /> Name: 1:611,ltivet L Phone: 2P16. 110 ;3I 6 '', <br /> Address: (2,7 ealt <br /> d ,iihtli /16 (E_ E-mail Address: <br /> l telia eState Zip o, <br /> Name: 54,n,„t Phone: <br /> Address: E-mail Address: <br /> City: State: 4s r <br /> •:.O blit,[] iOtif M rel a ,,�i2 . ,�Y:1 - �-',, ...:_4 _._"..... .,�J 'Sfl-,- - . u. <br /> Type of Food Service Establishment: `f � -4/, & vlit�Y�1fL_ ® td14/Z-1- / <br /> Local Building Inspection Agency: <br /> Water District: I Water Supply(check one): ❑ Private Well Public <br /> Sewer District: I Sewage Disposal(check one): Sewer El Onsite Sewage System <br /> inspection is based upon requirements of WAC 246-215; Rules & Regulations of the State Board of Health for Food Service <br /> Sanitation. Other agency approvals requisite to your operation may include County or City Planning, Building, Plumbing and Fire <br /> Departments, Water and Sewer Utilities. <br /> Signature of the owner or an offger of the legal ownership affirms the accuracy of the information provided in this application and <br /> that the permitteI <br /> be operated in compliance with the rules of the Washington State Food Code. <br /> Signature: <br /> ®ate: /2 alr <br /> ,Sa.o, <br /> Print Name: n �- li E JON �� <br /> _. . -.. FEe4cnV i <br /> /!3ery�eETT <br /> Environmental Health Division s <br /> 3020 Rucker Avenue, Suite 104 m Everett, WA 98201-3900 ® fax:425.339.5254 ® tel:425.339.5250 <br />