902 BROADWAY UMAMI 2020-01-21 - Laserfiche WebLink

1/ SNOHOMISH HEALTH DISTRICT WWW.SNOHD.ORG General Food Plan Review Application Application must be completed in full and submitted with fee and the items listed for processing: Reviewed by EHS Initials TYPE OF PLAN REVIEW (Check applicable box) 2/$500 (PE 5672)plus$185 per hour after 2 hours New food service establishment ❑ $185 Base fee plus$185 per hour for each add'I Remodel of existing food service establishment or revision of approved hour over 1 hour(PE 5685) plan El $335 Base fee plus$185 per hour for each add! Change of ownership/conditional operating permit AND remodel of hour(PE 5685&5642) existing food service establishment or revision of approved plan ❑ $185 (PE 5682) per inspection Reopen former food service establishment El $185 (PE 5670) New Limited Grocery,Tap Room/Tasting Room ❑ $185 plus lab fees (PE 5683) HACCP-when required by WAC for menu items ❑ $500 Base fee plus $185 for each add' permit New multiple permit food service establishment(large grocery store) (PE 5676&5675) ❑ $185 (PE 5677) Plan review consultation (On and/or off site) ❑ NO FEE Out of County Mobile (PE 56MR) Mobile o•erators from King or Pierce Counties ESTABLISHMENT INFORMATION MAILING ADDRESS Name: Vi/(,I Name: Ypty1 V( ✓I"9 Site Address: -LQ N. biackAkutuy AV2 un;te Mailing Address: NO R'bl Ave-• SE City: ZIP: City: :1-LA,L_ Ajeii,x-, State: jrl)H, ZIP: 7,52';,�$ OWNER INFORMATION Name: ��^ 1 )c Phone: (926-3,7- Address: )9 O 9 11 Ave._ SE E-mail Address: WAveYAn a 315 5 639rvrti(.core) City: J_cke_ 5. e4')S State: VUZip9 27.-5 CONTACT'INFORMATION (if different than owner) , 161V, !%%„ Name: -tail Peri )-tj� Phone: 6z6-377- 341 Address: le)0°I 19 ti lWe. S - E-mail Address: HS A rcrj Q yt0o- Gum City: 1-c 4 Ste•1/PinS State: WN Zip: ctS)-S OTHER INFORMATION Type of Food Service Establishment: Local Building Inspection Agency: Water District: Water Supply(check one): ❑ Private Well ❑ Public Sewer District: Sewage Disposal(check one): ❑ Sewer ❑Onsite Sewage System Inspection is based upon requirements of WAC 246-215; Rules & Regulations of the State Board of Health for Food Service Sanitation. Other agency approvals requisite to your operation may include County or City Planning, Building, Plumbing and Fire Departments, Water and Sewer Utilities. Signature of the owner or an officer of the legal ownership affirms the accuracy of the information provided in this application and that the permitted facility will be operated in compliance with the rules of the Washington State Food Code. Signature: 'i'- ,i ti()fl�►'ta Date: ?)1 ,2-01 j 1 ) c/ Print Name: f J I cam) UX7111 Environmental Health Division 3020 Rucker Avenue, Suite 104 ■ Everett, WA 98201-3900 ■ fax: 425.339.5254 ■ tel: 425.339.5250 ("