USDA Animal Welfare Act 5/23/2019

CITY According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information FORM APPROVED OMB NO.:0579-0036 unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0579-0036.The time required to complete this information collection is estimated to average.25 hours per response, No license may be issued unless a completed application has been received(7 U.S.C.2132-2143),and including the time for reviewing instructions.searching existing data sources,gathering and maintaining the date needed,and completing and reviewing the collection of information. the applicant is in compliance with the standards and regulations Section 2133. U.S.DEPARTMENTOF AGRICULTURE DO NOT USE THIS SPACE-OFFICIALUSE ONLY ANIMAL AND PLANT HEALTH INSPECTION SERVICE SEND THE COMPLETED FORM TO: USDA APHIS ANIMAL CARE APPLICATION FOR LICENSE WESTERN 2150 Centre Ave. (TYPE OR PRINT) Building B,Mailstop 3W11 Fort Collins,CO 80526-8117 (970)494-7478 X RENEWAL LICENSE NO./CUST NO RENEWAL DATE FEES 91-C-0104 26-May-2019 AMOUNT DATE RECEIVED 32737 1. NAME(S)OF OWNER(S)AND MAILING ADDRESS 2. ALL BUSINESS NAME,LOCATIONS,AND ALL SITES HOUSING ANIMALS(P.0.Box not City Of Everett acceptable) Parks&Recreation Dept. 802 E.Mukilteo Blvd. Everett,WA 98203 802 E.Mukilteo Blvd. County:Snohomish TELEPHONE ( ) Everett,WA 98203 /�i5,s1_ g�z3d COUNTY: Snohomish TELEPHONE (425)257-8300 �/� 3. IF PREVIOUSLY LICENSED—NAME AND ADDRESS 4. NAME AND ADDRESS OF OTHER BUSINESS(S)HANDLING ANIMALS IN WHICH _art 1 c V r APPLICANT/LICENSEE HAS AN INTEREST -))it)04..6 d C'GmvhLi 4S-i-ni SOP—An cL`S g c z L lM Late-LT-L.--a it t) �u E"='T i k 9S 26 3 PREVIOUS LICENSE NO.: al I - e_' a I o9 5. TYPE OF LICENSE 6. DATE OF LAST BUSINESS YEAR 0 A-Dealer(Breeder) 0 B—Dealer •C-Exhibitor FROM TO 7. NATURE OF BUSINESS(Check item that describes nature of your business) MO DAY YEAR MO DAY YEAR ❑ A—Zoo ❑ B-Aquariums ❑ C—Auction 0 5 2 6 1 9 0 5 2 6 2 0 ❑ D—Breeder ❑ E—Pets ❑ F—Roadside Zoo 8. TYPE OF ORGANIZATION ❑ G—Circus ❑ H—Animal Acts ❑ I—Carnival O Partnership 0 Corporation 0 Individual • Other(Specify) e/t y MU MG/PALL f ,6 Jr- 0 T❑ J—Drive thru ❑ K—Pet Store ❑ L-Broker Zoo 9. LIST OWNERS,PARTNERS,AND OFFICERS NAME AND TITLE ADDRESS CAfl„its FAN _/..-1 xi ^ m Amerz_ L__01 6A) vh m I vc-,s -- SKS D t P—Eer g.- to i & YN t)k*---) L-i ev f31., i) b car- L •- R�4-ec -ii v& e o� U, Au a2 1-7---7‘)-ems taA- `i g pe!)3 J Pcoo "1-A-ri)A)e12- 'Rr�s Glc no/6 sU i w 10. DEALER ONLY 11. EXHIBITOR ONLY(No.of animals holding now or held during the last business year,whichever is greater) 't �.` TOTAL NO.OF ANIMALS PURCHASED IN THE LAST CI4 1C- S filVEFS" BUSINESS YEAR .1)636-)46 ,Ae5 1 -- RABBITS 20 TOTAL NO.OF ANIMALS SOLD IN THE LAST �l MACSd BUSINESS YEAR Th NONHUMAN PRIMATES TOTAL GROSS AMOUNT DERIVED FROM THE SALE OF ANIMALS / _.� te MARINE MAMMALS G..� -�/� 1 /� WILD OR EXOTIC DOLLAR AMOUNT OF WHICH FEE IS BASED ^y MAMMALS (Sections 2.6 and 2.7) OTHER(i.e.,farm animals)(List C> WILD Species and No.) 45' CERTIFICATION I hereby make application for a license under the Animal Welfare Act 7 U.S.C.2131 et seq. I certify that the information provided herein is true and correct to the best of my knowledge. I hereby acknowledge receipt of and certify to the best of my knowledge I am in compliance with all regulations and standar.- in 9 CFR,Subpart A, Parts 1, 2,and 3. I certify that I am over 18 years of age. 12. SIGNATURE - '. 13. NAME AND TITLE(Type or Print) 14. DATE ' 0433,i,- +��1A r1rfi n �J /Z3 APHIS e'N17003 (Previous editions are obsolete) (JAN 1995) AP• •OVED •/:,0 -� •. AT .ST: .!A SD .ILES,CIti or 7 City Clerk