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! SNOHOMISH <br /> f_ ,.HEALTH DISTRICT <br /> WWW.SNOHD.ORG General Food Plan Review Application <br /> Appli•ation must be completed in full and submitted with fee and the items listed for processing: <br /> PU"Menu (Including beverages <br /> HACCP Menu Review <br /> ,);\c <br /> Plans &specifications Reviewed for completeness by F� rt EHS Initials <br /> YPE OF`PLAFI';:REVIEW (Check applicable box) :. <br /> $630 (PLU 333) New food service establishment <br /> O $168 Base fee plus$168 per hour Remodel of existing food service establishment or revision of approved plan . <br /> for each add'I hour(PLU 311) <br /> ❑ $168(PLU 335) Reopen former food service establishment <br /> ❑ $168 (PLU 334) New Limited Grocery <br /> • ' 0 $168 plus lab fees (PLU 385) HACCP=when req'd by WAC for menu items <br /> O $630 Base fee plus$150 for each New multiple permit food service establishment(large grocery store) <br /> add'I permit (PLU 366) <br /> ESTABLISISMENT INFOF ft ATIO� <br /> Name: '. �` C ': 1`Vi1:"\ %SA t,��.. . . . <br /> Site Address: '\:r) 1, VC 'K ' ('. CSI-Ti- " L3- <br /> City: <br /> �, v, <br /> C lig. E-� ZIP: t <br /> Name: „V P l\\ LCL' DES IQ 0 1\-) .. Phone: 4-2.5: 8`7 z <br /> Address: 2 �L ��U <br /> E-mail Address: Q C/2-Cb YR 14c=0• E--0 ; <br /> City: iq--e I' •1 i-i State: f P t oZip <br /> . CONTACT:INFORMATIOM{if:differen�tFi`anowner}. ,�: ,. .:.: - J <br /> Name: Phone: <br /> Address: E-mail Address: <br /> City: State: Zip: <br /> ,.;OTHER INFORMATION , <br /> Type of Food Service Establishment: <br /> Local Building Inspection Agency: <br /> I (check one): ❑ Private Well Water District: • <br /> Water Supply ) ,`?Public <br /> Sewage Disposal(check one): 0 Onsite Sewage System Sewer District: <br /> aSewer <br /> OFFICE USE ONLY __ <br /> : __ :...___:. -.. <br /> CI eri<11 724, r <br /> Inspection is based upon requirements of WAC 246-215. Rules& <br /> 0.0 <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. -.3'...77...T•••_-. . 33 ; _ =".,. . 630,:__ <br /> 630 <br /> /7/;292/1/1/1(1/7/2/ <br /> 1:647/:(74,/,`"'" <br /> APPLICAf 'r§rGNATURE DATE <br /> Environmental Health Division • • • • <br /> 3020 Rucker Avenue,Suite 104 ■ Everett, WA 98201-3900 fax:425.339.5254 Is tel:425.339.5250 <br /> 4y <br /> 4 <br />