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� <br />�� S��H��!�S� <br />�—�-� HEALTH DISTRIC I <br />� WWW.SNOHD.ORG <br />�er�era! Food Pla� F2e��ew. �4�plica�ior� <br />� <br />�pplicafion musf 6e completed in full and submitfed with fee and fhe ifems listed for processing: <br />❑ Mlenu (Including beverages � ?�.a�+,.�.�\`��u -�;��5�`��w, - <br />❑ H�CCP �llenu Review � �+� <br />;� Plans & specifications ' Reviewed for completeness by ��\� EHS Initials <br />\ � <br />TYPE OF PLAN REVIEIN (Check applicable 6ox)-: <br />❑$659 (PLU 333) New food service establishment <br />�$176 Base fee plus $176 per hour � Remodel of e>:isting food service establishment or revision of approved plan <br />for each add'I hour (PLU 391) <br />❑$176 (PLU 335) Reopen former food service establishment <br />❑$176 (PLU 334) i New Limited Grocery <br />❑$176 pius lab fees (PLU 385) �� HACCP-when req'd by WAC for menu items <br />❑$659 Base fee plus $157 for each � New multiple permit rood service establishment (large grocery store) <br />add'I permit (PLU 366) � <br />_ <br />eSTA8L15HNiENT INFORMATION <br />Name� 5� C3t1� t'k� 4��C>W �---� ��'D��-- <br />Site Address: 3S I(„� 2,���L�t._ �.l� <br />�,,�-,�- z�P: 9 �5�� i <br />c�ry ,:: <br />DINNER tNFORMATION ' <br />'� -�•,�_` Phone: �Z� _ � � 4 �� U <br />Name: f=.� c:.(�i-�l i ��'� i'-t � =_t <br />Address � 7�Ct� ��:'��`-.%� E-mail Address: <br />State: �� Zip: ��5 Z c� � <br />City� �.1�=�� _ <br />COPITl�CT INEORMATIQN (if different than owner) ` ' ` ' - ` <br />Name: -�c>:�� �-i- � ��-- Phone: �-i ZS - �L1 l3 — Z�i ) �S' <br />��3 iZ� �. �}- �.�...1 E-mail Address: ..�•. �L'- i�+=n� G��4'�Gl'=�'�j .CO'^ <br />Address: �' <br />State: � Zi : ��Zc) <br />City �.-�.r �,Z..�'f�- < <br />OTHER IPlFORMATION _ , , <br />Type of Food Service Establishment: ���� �-- <br />Local Buildinq Inspection Agency ^r �� C>� ��' "'�' �� <br />❑ Private Well Water District: , <br />Water Supply (check one): � Public �`'' '-` `- �� '~'` <br />Sewage Disposal (check one): ❑ Onsite Sewage System Sewer District: <br />'�d Sewer � �:.-' 3 � G <br />Ir�sp2ction is based upon requirements o�� WAC 246-215. Rules & <br />Regulations of fhe Stafe Board of Health for Food Service Sanrfation. <br />Other agency approvals requisite to your operation may include County <br />or City Planning, Building, Plumbing and Fire Departments, Water and <br />Sewer Utiiities. '� <br />_..'�i� -- - <br />f-.____ <br />/ \ <br />ICAt�IT SIGNATUR� <br />OFFICE USE ONLY <br />L'.y.�o;il'_:r'1!�;Ir, �'#; �il=� ';1�} .=..i <br />��. - `�� - T {. <br />; t-t:; �_ :n�,,_,icYa ?����'�i:_�- <br />"_�I�.�i—!r_ �.:� : � i _ al <br />- ; i_.'. i . i -' — _ <br />F`:.. i F� i= �= h <br />T11 <br />,�S t o �1C,� <br />DATE <br />Environmental Healfh Division <br />3020 Rucker Avenue, Suite 104 � Everett, WA 98201-3900 � fax: 425.339.5254 � tel: 425.339.5250 <br />