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<br /> <br />Food Permit Application <br />Chapter 500, F.S. <br /> <br />I", ac.;cordance will1 Chapter 000, F.S. The Department of Agriculture and Consumer Services is the 6)(c;ltls;ve regulalory and permitting authorir.,. <br />tor i'lflY person business or corporarior, engaged in manufacturing, proCeSlling, pllckiny, holding, or puop;uing fOOd 01 selling food III V'dlolesale <br />or retail. ~or purposes of this appllci'!ooo. food i~ considered to include, but is not limiter! to, all p'epi'lckaged grocery items, prepi'lfed foods, <br />packaged ic~. bottled or \Iend~d ....atcr. ci'lndy and other snack foo~, soda, inlanl formula. vitamin and m,neri'll dietary ,;upplements. <br /> <br />j <br /> <br />Florida Department of Agriculture and con;umer Services <br />BOB CRAWFORD, Commissioner / 8ur@au of Food and M8;ilt Inspection <br />Division of Food Safety 3125 Conner Boulevard <br />T~"ahassee. FL 32399-1650 <br />(850)468-3951 <br /> <br /> <br />:-< <br /> <br />Firm # 8850;;4844348 <br /> <br />INFORMATION ASOUT THE LOCATION TO BE PERMITTED <br /> <br />Tenitory. 447 <br /> <br />Firm Permit Type/Description 121 /CONi/ENt~NCE STORE W/f'S <br /> <br />( ) Renewal ~ New Business () Change of Owler () Other: <br /> <br />NamE' of Business <br /> <br />County <br /> <br />MERCHANT SO EXPRFSS <br /> <br />BusinE'6f> Location Address <br /> <br />F~1.{:) <br /> <br />Busin~!;s Location TOv..1 <br /> <br />lip <br /> <br />(317 GALL 8L VI.: <br /> <br />ZEfJHYRHILLS <br /> <br />,13541 <br /> <br />Do YO'.J manufacture and paCI(<lg<; Ice for' si'lle? ()J Yes { ) No. If Yes: Ihe fOllo.....n9 infurmation must bi:! Iiubmitted with the application: 1. <br />Indicate 60urce(s) of walp.r u~.ed for manufE'lcture. '}. Indicate any treatmfmt provided to the ice prior to packaging. <br /> <br />..... <br /> <br />lNFORMATION ABOUT THE OWNER <br /> <br />Check: one <br /> <br />) Sole ProprielO1 (} Partl,e:lsl1ip f><tCo1puri'ltion () Other: <br /> <br />l.egal Name of Owner <br /> <br />Phone # <br /> <br />Ext <br /> <br />KEVIN COOK <br />Business Mailing Address ) <br /> <br />(81.1j 779. 8203 <br /> <br />7317 GALL 8LVD <br />Business City <br /> <br />Business Stale <br /> <br />lip <br /> <br />ZFPHYRHILLS <br /> <br />n <br /> <br />33S41 <br /> <br />Ff!~ral Erllploye~ Identilicalio'l (FEIN) Number or <br />OVtfler's Social Security Number <br /> <br />Sales T <:IlC ... <br /> <br />59-2804490 <br /> <br />61-16-047711-01 <br /> <br />This application must be signed bv the applicanl OWler or chief exel;;utive of the applicant. without the need for v.itne3ses. If a corporation is <br />in 1he hands of a receiver 01 lrustee. this apptication shall be executed on beh<llt of the corporation by th(! receiver or trustee. I cenify that I <br />am empO~rf!d to execute this application as required by Chapter 500 ~.S, <br /> <br />DA <br /> <br /> <br />Title <br />