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�+ " SNOHOMISH � � <br />,� HEALTH DISTRICT , . <br />'NWW.SNONO.OP.G Ger-�eraf F�oa'Pfan ReviewAppficaPion � <br />Applicaticn must he completed i.� Iull andsubmiCed with /ee and the itemslis:ed forpracessing; <br />❑ hieru (Including f�everages � , � � � '. � � � � - � <br />❑ HACCP hienu Review � � � �. � � . . � ' . ' . <br />❑ Placs 8 speci;iwtions � ��. Reviewed (or ccmpleteness hy EHS lnitiats � <br />U 5630 iPLU 3?3) � <br />❑ 51 EB �ase fec plus 51fi'e pcn c�cr <br />,'or ezch add'I hcur IPLU 317) <br />L 5168 (YLU 335) � � <br />❑ 516E3(FLU334J ' <br />❑ 5168 lus lab `e=s (rLU 3S5J � <br />❑ SE30 ez;e `ee Ius 515C icr each <br />Site Address: 22 I 5 6 <br />Citv: ��lre.Ft—. .. � <br />��"OWNER INrORiv7ASION�=-;= <br />Namc: .�o.m���� Lc�c <br />nddresr. 1(�1c� Se n1�6 <br />Ci;Vf \,IAn�uva� <br />Ne�.v fcod <br />Remodel o` existing faod serv'ce estahlishment or revisicn o( apprcved pian <br />Recpen fermer foed service estahlishm=nt �� � � <br />Netv Limited Grccer� <br />V�li,C `cr rr.enu ilems <br />Dlew meltiple permit fccd service establishment Qarr,e grccery slcre) <br />� Western <br />� Constructiou <br />�_.;,_ Services, Inc. <br />tJa -. V:cs:nh 1i:�F lommee.',a� lon;nucUuc <br />Or l C QP.6:717 µ��.�v wMinnccnslnicbcn cam <br />Caf! Eby s�������������i���� <br />Eo.qo�I.os-ry <br />E-mailAdcres;i �a..-.��:�.I��,:lac��F,�c4.•,cs�6S•c „` <br />State: W4,� � Zio:9E683 <br />iJ�[C_ I(.t� y�,r.,,,1- <br />sewcr <br />v.���c 1360) 6995317 � . <br />'300 �.ut itn�d LOop. Swie I IU toll Frre (800) 699�ti317 ��� � . <br />l'a•uauvrr, 11'.1 �86b1 fd< 13G0) 694-7.91$ ' � . <br />�.u1•.:1v�;b•�ni�iutrucLonroin Ccll (206) ?i6�96G7 <br />� 15. Rules E <br />Regulaliors o1 tne atale acam or neaim rorrcee aen�lce Sar,itafion. <br />Other agency apprcvais requisile lo your operatlon may include Counry <br />or City Planning, �uilding, Plum6ing and fire Ocoarimenls, Nlat?r and <br />Sewer Utililie,, � � � . � <br />.�i_��.2- _�/� L_ I—�7—�.� <br />� APPLICANT SIGNATURE DATE <br />ii(ICI:L, . . <br />,_u�,�i� P�61,� Wo��s <br />...,_..���r�w P..61,� �,J.�-I<S <br />, � UtrlGt U5L- ONLY� : ;-, r': '.?, �.' <br />. � ,. . � . .� .� "" <br />' .. <br />al:t�. �'te:.�JS'.. f.'i� _ : . <br />�t. -, <br />G 3n=_21F_,dP Ipn.', evi=s_E FI 0:_47 I�_L•;�r. <br />Environmental Health-Division— --- ' ' <br />30ZD P,uck�r Avenue, Suife 104 a Evere�i, 4YA 98201-39C0 n fox: 425.33?.5254 o tel: 425.334.5250 <br />- �- <br />