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SNOHOMISH <br /> HEALTH DISTRICT <br /> WWW.SNOHD.ORG General Food Plan Review Application <br /> / <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 /> ❑ Plans &specifications Reviewed for completeness by EHS Initials <br /> TYPE_IF PLAN REVIEW (Check applicable box) <br /> 01 671 (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 add] 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! permit (PLU 366) <br /> ESTABLISHMENT INFORMATION <br /> Name: t/Gc`' <br /> Site Address: / 7 3 /32.7_,,---4jl �l <br /> City:y t 3:�5%—/ l�� /,1 '1 ZIP: <br /> OWNER INFORMATIQN, <br /> Name:' >/l7ci /0-7/ Phone: .76:P <br /> Address: es-5-z; � Zeit' /c/%�` E-mail Address: z '�� ���� � r •.i5i� <br /> City: gL State: 4 Zip: -/--.1„:>%7Z-1-1, <br /> CONTACT INFORMATION(if different than owner) <br /> Name: Phone: <br /> Address: E-mail Address: <br /> City: State: Zip: <br /> OTHER INFORMATION <br /> Type of Food Service Establishment: it Zi4 (4-71 tel} i7 <br /> Local Building Inspection Agency: <br /> Water Supply(check one): <br /> CI Private Well Water District: <br /> ❑ Public <br /> Sewage Disposal (check one): ❑ Onsite Sewage System Sewer District: <br /> ❑ Sewer <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 /> 41111Lb C! <br /> APPLICANT SIGNATURE DAT <br /> Environmental Health Division <br /> 3020 Rucker Avenue, Suite 104 ■ Everett, WA 98201-3900 ■ fax: 425.339.5254 ■ tel: 425.339.5250 <br />