2900 GRAND AVE BB RANCH 2018-09-11

Change of Ownership Statement Date of Ownership Change: Former Establishment Name (if changing): Previous Owner Name: Is facility currently open? ❑ YES El NO Will facility remain open? El YES 0 NO If no, what is your reopening date? Copy of menu submitted. (REQUIRED) ❑ YES ❑ NO Will there be changes to kitchen and/or equipment? 0 YES ❑ NO If yes, briefly describe changes: Please initial each statement indicating you have read and understand them: I understand my facility will be inspected by Snohomish Health District within 30 days. I understand that a fee(s) will be charged if additional inspections are required. I understand that changes and/or improvements may be needed. I understand that all changes and/or improvements must be completed by the date listed during my inspection. I understand that my facility may be closed if changes and/or improvements are not completed by the date listed during my last inspection. I understand that I may need to make changes that were not required of the previous owner. I understand that all changes to menu, equipment, and the building must be approved in writing by Snohomish Health District. I understand that I may be required to submit a remodel plan review which has additional fees. I understand that my permit expires December 31 of each year and must be renewed at that time or late fees may be assessed. Print First& Last Name(s): Owner/Representative Signature: You are NOT APPROVED to operate until after inspection. Date SHD Initials You are APPROVED to remain open pending inspection. This 30-day conditional Permit to Operate expires on: POST THIS PAPER IN A CONSPICUOUS AREA Date SHD Initials