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HomeMy WebLinkAboutM_Various Submittal Items_180227_v1-DEPARTMENTOFCOMMUNITYANDECONOMICDEVELOPMENTLDIdCityofRentonPlanningDivision1055SouthGradyWay,Renton,WA98057Phone:425-430-7200Fax:425-430-7231I,&IxOJ\”cincccpc,beingtheApplicantfortheTemporaryUsePermitattheLocationof:2Snc\kNcNnP-\HerebyauthorizetheCityofRentontosummarilyeliminatetheTemporaryUseandallevidenceoftheuseitithasnotbeenremovedasrequiredbythetermsofthepermit.IalsoagreetoreimbursetheCityforanyexpenseincurredinabatingthisTemporaryUse.Signature:JOC1I”.iPôJS?rintName:.471”osoq-,vcPcDate:0)—ISLL?STATEOFWASHINGTONCOUNTYOFKING)55ft(N2eVIcertifythatIknoworhavesatisfactoryevidencethat—Accp.,NSecersignedthisinstrumentandacknowledgedittobehis/her/theirfreeandvoluntaryactfortheusesandpurposesmentionedintheinstrument.Dated:(‘P—S-\9NotaryandfortheStateofWashingtonNotary(Print)Et)’qA‘R__...ncMyappointmentexpires:OS-Ok—.C,\Ck-2-ABATEMENTAGREEMENTTEMPORARYUSEH\CED\Data\Fcmis-Templates\Self-HelpHandouts\Planning\TempcraryUseTier1dcc05/14 It’.iIaaII—,CQttIaIUi!Ii.tUUllt)f—aaaatj.ISeattle’&KingCountyGHPNumber:PR0082506FANumberFA0039900BUSINESSNAMEANDADDRESS:TAQUERIALOSPOTRILLOS960016THAVESWSEATTLE,WA98106TAQUERIALOSPOTRILLOS6211RAINIERAyESSEATTLE,WA98118Makeanychangesforyourbusinessonthisform.Orpayonlineifnochangestoyourbusiness:VNNJ.kingcounty;yov/health/portal2017APPLICATIONFORRENEWAL6783-MobileFoodUnit-RiskCategoryIIITAQUERIALOSPOTRILLOS#3L7>‘MAR3c2017ENVIRONMENTALHEALTHSERVICESKingCountyFederalIDNo.91-6001327MakeCheckspayableto:SKCDPHPublicHealth-SeattleKingCounty401FifthA’enue,Suite1100Seattle,WA98104BFOODYEARPENTCREDITCiRD—0—2M7110GML1070.00107C.0049’Ui2:7ThPhone:(206)263-9566OWNERSHIPCHANGE:(updateifneeded)ChangeofOwnershipCurrentownerofrecord:Nameofowner:GAMALIELMARTINEZAddressofowner6211RAINIERAVESSEATtLE,WA98118DaytimePhone,Email:NewOwnerName:—NewOwnerAddress:OPERKflONCHANGE:(Ifapplicable)QPreviousBusinessClosedWhenwastnepreviousbusinessclosed(pleasecircle)?-Lessthan90Days-90Daysto1Year-1Year+-UnknownClassificationChangeHastherebeena:(pleasecircleallthatapply)-ChangeinMenu?-ChangeinnumberofSeats?-ChangeofEquipment?-ChangeinLayout?NewBusinessName:NewMailingAddress:City:___________Email:ZipCode:DaytimePhone:PAYMENTINFORMATION:-Topaybycreditcardore-check,payonlIneat:www.kingcounty.govlhealth!portalThereIsnotransactionfeeforonlinepayments.CheckorMoneyOrderPayableto:SKCDPHReturncheckormoneyorderpaymenttotheaddressabove.Ifpayingbymail,besuretoincludethisformwithyourpayment.MAILINGADDRESS:87DUEDATEAMOUNTDUE31311201751,070.004/10/201751,177.00includingSlOT00tatefeeIFPAID4/30/201751,28400including521400latefee5130(2017$1,391.00:nc!uding$321.00latefeexSIGNATUREOFAPPLICANTDATELIZipCode:PERMITCHANGE:(pleaseupdateifapplicable)QMailingAddressChangeQChangeofBusinessName5080v25.mt I‘-ç,/s4..-’?ubliciiealthMAR92017Seattle&KingCounty]AppendixCUseofCommissary/SharedKitchenAgreementAllFoodEstablishmentsmustoperateoutofanapprovedfacilitylocatedwithinKingCounty.ManyfoodoperationssuchasMobileFoodUnitsandCaterersutilizecommissariesthatarenotundertheirownownership.ThisformshallbecompletedifyouarenottheownerofthecommissaryorIfyouwillbesharingkitchenfacilitieswithothervendors.Thecommissarymusthavefacilitiesforsupplystorage,equipmentcleaning,foodpreparationandotherservicingactivities.Minimumplumbingrequirementsforacommissaryincludea3-compartmentsink,amopsinkfordumpingwastewater,andahandwashsink.Anindirectlydrainedfoodpreparationsinkwillberequiredifproducewashingoccursaspartofthepreparationactivity.Plan/Permitapprovaliscontingentuponthoroughdocumentationoftheservicingactivitiestobeperformedatthecommissary.Providescaledrawingsofthecommissarykitchenshowthgthefoodserviceequipmentandstoragetobeused.(Alloftheseitemsmustbeaddressedasincompleteplansubmittalsmaydelayapproval.)indicatewhichofthefollowingserviceswillbeallowedforuseatthecommissary:3-CompartmentSinkHandWashSinkFoodPrepSink-CommerciaiRefrigerationSpaceDryStorageSpace(Linearsquarefeet)FreezerSpaceRestroomAccessIceMachine.$eyAccessibilitytoCommissary(Ifnecessary).CookingEquipmentPreparationTable/EquipmentMopSinkOffStreetParldngfortrucks/trailersOther:____________________________CommiaInfoaio:meofBusinesjAiEfrleI’yAddress:.City:tfl-f-Zip:gpc;pContactPerson:ITitle:f)IflhUI’Email:_________________________________________________Phone:________________________________________BusinessHoursofOperation:lOAM—Doothervendorsusethiscommissary?YesQNoIfso,howmanyI’SMobileniCerer/VonritoIn:NameofBusiness:LACYittinSpHri((vs3Owner/Operator:TitleYUUJIJ’Enaii:_________________________________________________________Phone:_______________________________Address:IWJO54ns-’kytUVCityJtfltOflZip:flOflQDaysimeatCommissary:(0cM—IIø’-4A1a/’c/,tk/nc/(CommissaryOwner/Agent—PrintedName&Title)(MobileUnit/CatererNendor—PrintedName&Title)J2,Ljefr&/Jpø__________________(CommissaryOwner/Agent—Sidnature&Date)(MobileUniUCatererNendor—Signature&Date)Thisagreementbetweentheownerofthecommissaryandtheoperatorofthemobileunit,catererorvendorsigniflesthatbothpartiesagreetothealloweduseofthecommissaryasspecified.NotethatthisagreementIsnottransferable.ShouldtherebeachangeinownershipofeitherthecommissaryormobileunIt/caterer/vendor,orshouldtherebeanymodificationorcancelatlonofthisagreementbetweenparties,thenthePublicHealth—Seattle&KingPermanentFoodServiceEstablishmentPermItmaybesuspended.AvailableinalternativeformatuponrequestpursuanttoADAForOfficeUseOnly:HealthOfficerapprovalforuseofcommissarybythemobilefoodunitowner/vendoridentifiedabove:HealthandEnvironmentallnvesligator/MPRAFComplianceOfficer:(Date(PrintedName)(SlgnaturejDISTRICThEALThCEN1’EI{SD9’NTrnyNEASTGATE40!5AveIV’Floor14350S.E.EasigateWaySeattle,\VA98104flellevueVA98007206-263-9566206-177-8050S:\EIISHARE\TECHDATA\Food\FoodForrns\2016FoodFomu