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SNOHOMISH HEALTH DISA — <br /> General Food F SNOHOMISH HEALTH DISTRICT 3020 Rucker Ave, Suite 104 <br /> 3020 Rucker Ave, Suite 104 Everett, WA 98201 <br /> Everett, WA 98201 425.339.5250 <br /> submitted with fee and the items list( 425.339.5250 <br /> 09/23,'15 Invoice Invoice # 300260358 <br /> Reviewed for coml 09/23/15 Invoice Invoice # 300260361 11:01 am <br /> 11:13 am <br /> box) = Sales Person: 327 Register #:302 <br /> Sales Person: <br /> food service establishment 327 Register #:302 � � `"--'------ -- - <br /> ------------------------ ----- <br /> Change of Ownership - ---_- <br /> odel of existing food service establish Plan Revision - alt exist/hour - i @ 132.00 each 132.00 <br /> 1 168.00 each Plan Rev Site Insp reopen form <br /> en former food service establishmen� __--_r- - --168.00 168.00 each <br /> 168.00 <br /> -------------- ------ - <br /> Limited Grocery 1 �Sub-Total: __"------ <br /> 168.00 <br /> :P-when req'd by WAC for menu Re --------------------- Sub-Total: 300.00 <br /> --------------------- <br /> nultsple permit food service establist - -Tota 1: ------------------ <br /> 77777777�- _ **********9034 ** *� 168.00 ----------__ <br /> **/**Debit: 168.00 Total: 300.00 <br /> -------- __ ------- ******0**8034 **/**Debit: 300.00 <br /> -chen5 Total Paid:-- - 168.00 <br /> Way �3 Change: 0.00 Total Paid: 300.00 <br /> ZIP: yg 2 Change: 0.00 <br /> Phone: 412 - <br /> E-mail Address: .c 77 tion. _ <br /> State `lti'4- Z, 5 Z 03 <br /> RISK CATEGORY <br /> Phone: <br /> ❑ A (Low) <br /> E-mail Address: ❑ B (Medium) <br /> State: zip: ❑ C (High) <br /> � Cc�rri� I�14ri�c�;7 OFFICE USE ONLY <br /> Water District: <br /> C i 'tf ivered/PU <br /> :wage System Sewer District: I <br /> pate/Initials <br /> L'rY ca + �L'Prc7� <br /> OFFICE.gJ I .O.NLY <br /> 6-215. Rules& = - <br /> Service Sanitation.may include County - --_ - <br /> rtments,Water and _ <br /> . ' :s:ci;iishmentD5r^li:A,--o1 =— 2-014 k-- <br /> DATE - <br /> '54 ■ tel: 425.339.5250 <br /> 'A 98201-3900■ fox:425.339.5254 IN tel:425.339.5250 <br />