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,(4s SNOHOMISH <br /> HEALTH DISTRICT <br /> WWW.SNOHD.ORG General Food Plan Review Application <br /> Application must be completed in full and submitted with fee and the items listed for processing: <br /> Menu (Including beverages <br /> ❑ HACCP Menu Review <br /> D 5�Ck k i.' 2���2o/E <br /> it !/� <br /> [ Plans &specifications JL = ` LF Reviewed for completeness by ftZ EHS Initials <br /> TYPE OF PLAN REVIEW (Check applicable box) <br /> ❑ $ 671 (PLU 333) New food service establishment <br /> $180 Base fee plus $180 per hour Remodel of existing food service establishment or revision of approved plan <br /> for each addl hour(PLU 311) <br /> ❑ $180 (PLU 335) Reopen former food service establishment <br /> ❑ $180 (PLU 334) New Limited Grocery <br /> ❑ $180 plus lab fees (PLU 385) HACCP—when req'd by WAC for menu items <br /> ❑ $671 Base fee plus $160 for each New multiple permit food service establishment (large grocery store) <br /> add'I permit (PLU 366) <br /> ESTABLISHMENT INFORMATION <br /> Name: Cr"rsitr 1- , Y O{J <br /> Site Address: )4;510-- 1V <br /> City: - ZIP: 1003 <br /> 'OWNER INFORMATION <br /> Name: Sec c i K< v-, Phone: —31-`- — S-s1Z <br /> Address: 1 ))- J('✓I"/.1 p k1 E-mail Address: <br /> City: EV-er---•t State: 4'v P Zip: CIS`>03 <br /> CONTACT INFORMATION(if different thanowner) <br /> Name:�6SCUa-14QOI" . Phone: q2s. <br /> 3A5 <br /> Address: (O1J2- .vriV E-mail :SS�� L (l <br /> City: ZVC' + State: v Zip: Gg <br /> •(U <br /> OTHER INFORMATION <br /> Type of Food Service Establishment: <br /> Local Building Inspection Agency: <br /> Water Supply (check one): ❑ Private Well Water District: <br /> Public <br /> Sewage Disposal (check one): ❑ Onsite Sewage System Sewer District: <br /> jgcSewer <br /> OFFICE USE ONLY <br /> Inspection is based upon requirements of WAC 246-215. Rules & <br /> Regulations of the State Board of Health for Food Service Sanitation. <br /> Other agency approvals requisite to your operation may include County <br /> or City Planning, Building, Plumbing and Fire Departments,Water and <br /> Sewer Utilities. <br /> t /2-61,,$)PPLICANT SIGNATURE DATE <br /> Environmental Health Division <br /> 3020 Rucker Avenue, Suite 104 ® Everett, WA 98201-3900 e fax: 425.339.5254 ■ tel: 425.339.5250 <br />