Laserfiche WebLink
APPIi1CATlON FO�t ANNUAL FOOD SER�ICE ESTARLISHMENT PERMIT <br /> POR HGAI,TH DISTRICT USG <br /> 1>stablishmcn�Namc Permit N <br /> Cstnblishmcnt Phonc Numbcr lanail Address <br /> Mail i Dclivcry/PU ny/Dme <br /> Risk Caicgory: ❑A ❑B QC <br /> Sirccl Address <br /> Cily "1_IP <br /> Owner Owncr Phonc Numuer <br /> Maiiing Address(if difTcrcnl from cstablislimcnl) <br /> Ciry S�atc 7_IP <br /> � Cl�mtge in nrvncrship7 Pleasr chcck d�c Gns und,fill in d�c <br /> I7CCCSlCGI J'O7/Oi'p7l!/10I7 O7t UIB IJGCIC O'(I71.t'Gf)fJI1CG!l017. <br /> Pcrmits arc NOT fransfcrablc. <br /> Permits are valid through Decembcr 31. New permits issued on or after tl�e following dates are pro-rated as <br /> follows: April 1" —+ 75%of annual fee; July 1 S' � 50%of annual fee; October 1"' —� 25%of annaal fee. <br /> �� Signaturc Date <br /> FOOD ESTAI3LISHMENT CATGGORY: Mark thc appropriate calegorics,comnlete the application,and submit the ori i al, <br /> wlor-coded epplicalion wilh correct fec. (See cm•irrvl jee sched�deJ <br /> l.encral Pood Permit—includcs bm noi limi�ed io ❑ Athletic Pield Concession Stand <br /> restaurant(with or a-itliout loungc),conccssion sland,food � Groccry <br /> sland concession,commissap-,bakery,catcrcr,gruccry, <br /> limi�ed grocerv,privatc club,rctail mcal dcalcr,rciail fish ❑ JVith bakcry__scats <br /> dcaler,tavem,year round campground/park food service � y,��th dcli _ seats <br /> ❑ Calering Addlfinnnl%15 iec nnd cnrcrine menu � �y����ineaUfish <br /> rcaulred jnrjncl/i/ic.v�Im�alsn proridc <br /> cn.•er7ng scrr7ces. ❑ With specialq�fish area <br /> ❑ 0-12 scats InduAc larmgc senls. ❑ Other <br /> ❑ 13-50 seals ❑ O�hcr <br /> ❑ 51-i 5� seats ❑ MobiL^ Pood Vehicle (see bclow) <br /> ❑ 151-250 seats <br /> ❑ Ovcr 250 scats <br /> I'or Food Stand Concession or Mobilc �ood Vehicle, hlca�c include ihc followmg infomiation if applicable: <br /> Commissary: Itatroom: License plate#: <br /> Rcfcr to back nt'pac!c for ndditiunal requircments. �t�����'������� <br /> / SNOHOMISH ENVIRONMEN�ALHEALTHDIV�SION pUBLIC HEALT� („ <br /> Food Program �LWAYS W:IRKINO f01111 OAFER AND <br /> HEAi.TH 3020 Rucker Avenue, Suile 104 HEALTNIER OO�UMJE r <br /> DISTRICT Ere�etl,1'JA 98201-3P00 <br /> 425.339.5250 Fax:475.'?39.525d <br />