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41024-okk, <br /> 0,46' SNOHOMISH � z ��1 _u� �� <br /> 41 HEALTH DISTRICT <br /> WWW.SNOHD.ORG Food Stand/Mobile Food Unit Plan Vew <br /> Application must be completed in full and submitted with the correct fee. e9,/p <br /> HD Initials Reviewed by S Srr <br /> TYPE OF PLAN REVIEW (Check applicable box) `P 0-2 <br /> El $464 Plan Review& Inspection Fee(PE 5678) ❑ Food Stand Concession (New) Pe�wit op�. <br /> ❑ Mobile Food Unit(New) VE� <br /> ❑ $195 Alteration to Existing Establishment or Changing your commissary or revising your approved plan. Ira* Fr <br /> Revision of Approved Plan (PE 5685) preoperational inspection. <br /> ❑ $0.00 Mobile Approval by Reciprocity (PE 56AN) For mobile food units currently permitted by their primary county. <br /> ESTABLISHMENT INFORMATION <br /> Name:The Grape & Grain <br /> Site Address:6502 Evergreen Way, Suite A <br /> City:Everett State:WA Zip:98203 <br /> Unified Business Identifier(UBI):604-612-939 <br /> MAILING ADDRESS <br /> Name:Liquid Provisions, LLC. <br /> Address:708 100th Ave SE <br /> City Lake Stevens State:WA Zip:98258 <br /> OWNER INFORMATION <br /> Name:James Eric Brown Phone:404-807-3239 <br /> Address:708 100th Ave SE E-mail:grapeandgraineverett@gmail.com <br /> City:Lake Stevens State:WA Zip:98258 <br /> CONTACT INFORMATION(if different than owner) <br /> Name: Phone: <br /> Address: E-mail: <br /> City: State: Zip: <br /> COMMISSARY INFORMATION <br /> Name:The Grape & Grain <br /> Address:6502 Evergreen Way, Suite A <br /> City:Everett State:WA Zip:98203 <br /> I understand I cannot open this food establishment until I have received written approval from the Snohomish Health <br /> District, obtained all annual operating permits, and have been inspected and approved by all applicable city, county and state <br /> agencies. <br /> Signature of the owner or an officer of the legal ownership affirms the accuracy of the information provided in this application and <br /> that the permitted facility will be operated in compliance with the rules of the Washington State Retail Food Code(WAC 246-215). <br /> Signature: Date: <br /> Print Nernl: <br /> Environmental Health Division <br /> 3020 Rucker Avenue, Suite 104 ■ Everett, WA 982G1-3900 ■ fax:425.339.5254 ■ tel: 425.339.5250 <br />