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SNOHOMISH <br /> ,41) HEALTH DISTRICT <br /> W W W.SNOHD.ORG Annual Food Establishment Permit Application <br /> Application must be completed in full and submitted with fee and the REQUIRED items listed for processing: <br /> ❑ Menu(Including beverages) <br /> O Food Flow Sheet(HACCP) <br /> ❑ Commissary Letter1Food Stand Concessions& <br /> ❑ Restroom Letter Mobile Food Vehicles only Submittal Complete EHS Initials <br /> Establishment Name: Site Phone: <br /> Establishment Address: City/Zip: <br /> Owner Name: Owner Phone: <br /> Mailing Address Of different): City!St/Zip: <br /> Email Address: <br /> Signature of the owner or an officer of the legal ownership affirms the accuracy of the information provided in this <br /> application and that the permitted facility will be operated in compliance with the rules of the Washington State Food Code. <br /> Signature: Date: <br /> Print Name: <br /> ❑ New establishment <br /> ❑ Change of ownership (PLU 301)--Must complete reverse side of application. <br /> GENERAL FOOD MULTIPLE PERMITS RISK CATEGORY <br /> • <br /> ❑ 0—12 Seats (PW 374) ❑ Grocery ❑ A (Low) <br /> ❑ 13—50 Seats (PLU 375) ❑ Bakery ❑ B (Medium) <br /> ❑ 51 --150 Seats (PLU 376) ❑ Deli ❑ C (High) <br /> ❑ 151 —250 Seats (PLU 377) ❑ Meat!Fish <br /> ❑ Over 250 Seats (PLU 378) 0 Specialty Fish OFFICE USE ONLY <br /> 0 Other PERMIT# <br /> OTHER <br /> O Catering Only(PLU 374) Mailed!Delivered I PU <br /> Date/Initials <br /> ❑ Mobile Food Vehicle(except frozen foods) (PLU 303) <br /> Permits are valid through December 31 and are NOT transferable. <br /> • <br /> New permits issued on or after the following dates are pro-rated: <br /> April 1—75%of annual fee <br /> July 1—50%of annual fee <br /> October 1—25%of annual fee <br /> (Does not apply to fee for change of ownership.) _r� <br /> AnnusiFoodEstabliGhmehtRarr;itAppLEH_2c," <br /> Environmental Health Division <br /> 3020 Rucker Avenue,Suite 104 11 Everett, WA 98201-3900■ fax:425.339.5254 ■ tel:425.339.5250 <br />