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<br />
<br />APPLICATION FOR;s:; ,
<br />PLAN REVmWf~d.\ .
<br />, O~~~V~~S
<br />
<br />Address '874-7 Ter.fte.. Te.rt~,e. il""l City Tu-- ~ 7e;r~:.::L
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<br />State & Zip Code -'- '3 }/,,~ 1 . Telephone (~l..Jl!L >-(
<br />. ~~. (0") f...:.-~
<br />1 Responsible Agent: Name :-) ~ ." LA') . WI" l<A-- Title
<br />or It"", thin oWNrl
<br />
<br />Address (~?ltY3 ~30 I City
<br />,.... .fL ZlpC,', 3 :';0'1- . T,I,p'''' rS51J5il:2:-
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<br />..
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<br />Please Print or Type
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<br />
<br />I Establishment Name
<br />Cotpout. ,nd ,uUIt name
<br />wbtf1lppIOprilt.
<br />
<br />c
<br />
<br />1 Establishment location 1 '2
<br />Addt.u 'Ad City
<br />
<br />
<br />2.6
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<br />10wner Name
<br />
<br />
<br />AJ G;- ~.(
<br />
<br />
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<br />I Menu Information: Types of food involved and method of servicg. Attach a copy of proposed menu
<br />flf necessary),
<br />
<br />I Waste Water Disposal. Prior to the opening inspection, the applicant must provide written
<br />approval for waste water disposal from the appropriate agency (HRS County Public Health
<br />Unit, Department of Environmental Protection, municipality or sewer district), Written ap.
<br />proval may be a copy of a utility bill, a receipt or permit, or a letter from the appropriate
<br />agency,
<br />
<br />Will your establishment be served by:
<br />
<br />A. Septic tank system? 0 Yes
<br />a Package sewer plant? 0 Yes
<br />C. Municipal[utility seWer? taYes
<br />
<br />ONo
<br />DNo
<br />DNo
<br />
<br />If you answered YES to item B or C, complete the following:
<br />"-.,
<br />Name of municipal/utility agency CITY Or 26 PH"if( H II..L..s
<br />
<br />Size of grease trap 150 gal. location ~e~
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<br />i Water Supply. Prior to the opening inspection, the applicant must provide written approval
<br />for a potable water supply from the appropriate agency IHRS County Public Health Unit,
<br />Department of Environmental Protection, municipality or sewer district). Written approval
<br />may be a copy of a utility bill, a receipt or permit, or a letter from the appropriate agency,
<br />
<br />Will your establishment be served by:
<br />
<br />A. On,sitewaterwell? DYes
<br />B. Municipallutifitywater? ~Yes
<br />
<br />DNo
<br />oNo
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<br />If you answered YES to item B, complete th~ following:
<br />
<br />Name of municipal/utility agency
<br />
<br />err...,.
<br />
<br />OF :Z6PHY~IL.L'$
<br />
<br />I . . I . I I
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<br />
<br />D Basic Faci/it Information
<br />
<br />o New Construction
<br />o Conversion of existing
<br />structure to food service
<br />
<br />o Closed at least one year
<br />Ji:I Remodeling of existing food service
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<br />Name of existing public food service establishment
<br />
<br />d~/'u...
<br />
<br />CAFe MAP,e.IO
<br />
<br />
<br />iii If existing structure, provide description (examples: steel warehouse,
<br />old wood frame bu~ding in historic district, etc.):
<br />
<br />tSHof'PlI4-G CeN'Te~
<br />
<br />2-
<br />Note: Constru:tion fJl1ish schedules of noor, walls and ceiling rT'.Jst be provided on floor
<br />plans,
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<br />IJlI Solid Waste Disposal.
<br />Disposal Type (dumpster, grease container, garbage can, etc.)
<br />
<br />01 j foo1.f'c:;-r~
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<br />Waste water from cleaning containers disposed on site?
<br />
<br />DYes 0 No
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<br />m Will establishment have an Alcoholic Beverage license?
<br />
<br />o Yes ~No
<br />
<br />If YES, the estabfishrrent must meet all the sanitary requirements of the state before tfe departrr.ent
<br />staff may S9n the apprcation for beverage rCerlSe. AD required eqliprrent and fixtt.l'es ITLISt be instaKed
<br />and operatirYJ properly before approval can be given pursuant to s,561.17(2), Florida Statutes,
<br />
<br />m Projected Seating Capacity: Number of Seats
<br />
<br />~
<br />
<br />[()
<br />
<br />(Y)AX
<br />
<br />mConstruction: Anticipated Start ~Ikl 00 Completion 1.2...1.212) 00
<br />Manl!'! D.y Yut MMlh O'y rur
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<br />Plans are reviewed on a first-come, first,served basis. Florida law allows 3D days for processing,
<br />Atter plans are approved and ccnstruction is complete, please contact your tfrvUicr. 6strict offiCI! fer
<br />an inspection, It you do not elmently hold a BPR license for this establishment, s~bmittal of an
<br />ApprlCation for Ucense and the appropriate icense fee is requird at the tme of the c~e:ing inspect:cn.
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<br />'i13-7i;.-/l'1,
<br />
<br />ke:~
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<br />......~
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<br />SIGNATURE OF APPLICANT
<br />
<br />ie/Db Iou
<br />MONTH DAY YEAR
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<br />
<br />R Form HR 5021,010 IFormerly BPR 21,010)
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<br />, I ,
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<br />. . . I
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<br />R!'I!lid 19~9 JI;:Y 29
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