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<br />
<br />v ,,,,{llE:~r&.\ D~:~TMENT OF BUSINESS AND PROFESSIONAL REGULATION
<br />... ~,-- ~ ~ DIVISIOn of Hotels and Restaurants
<br />~.< 'APPLICATION FOR
<br />PLAN REVIEW
<br />
<br />
<br />'Estahlishment location 1 '2
<br />Addrru and City
<br />
<br />
<br />ze
<br />
<br />'Owner Name
<br />
<br />
<br />C^-'lC:C
<br />
<br />
<br />Address ~ }4-7Te;rfce. re.ftr;~(.e. It vJ 't
<br />
<br />City
<br />
<br />~;.< t-f... (efr.:....':;;....
<br />
<br />State F.L Zip Code ~>t.{ 1 . Telephone (3/;. tJjl:,)./
<br />~~.G)~,-
<br />Responsible Agent: Name ..... ~~1I\.Q." lA,) .1l"~/",R.lY Title
<br />at OU...,lhln oWNrl
<br />
<br />'dd"" (:.1 ?,()"\ ~L~ I
<br />State .fL Zip Code '3 l~~.:2~
<br />
<br />
<br />City
<br />
<br />Telephone r '35:1 ).562-
<br />
<br />Menu Inlonnation: Types oUood involved and rrethod of servic~, Attach a copy of proposed rrenu
<br />Crt ro:essaryl,
<br />
<br />d~I' u..
<br />
<br />Name of existing public food service establishment
<br />
<br />CAFf MADJC:,IO
<br />
<br />BPR license number 01 existing public food service establishment
<br />
<br />o If existing structure, provide description lexamples: steel warehouse,
<br />old wood frarre bu~ding in historic district, etc.):
<br />
<br />cSHoPPt~G CE.N.:re.R
<br />
<br />2-
<br />Note: Constnx:lion finish ~hedules of floor, walis and ceiling rrusl be provided on flocr
<br />plans,
<br />
<br />M Solid Waste Disposal,
<br />Disposal Type (dumpster, grease container, garbage can, etc.)
<br />
<br />Waste Water Disposal. Prior to the opening inspection, the applicant must provide written
<br />approval lor waste water disposal from the appropriate agency fHRS County Public Health
<br />'Jnit, Department of Environmental Protection, municipality or sewer districtl, Written ap..
<br />Jroval may be a copy of a utility bill, a receipt or permit, or a letter from the appropriate
<br />1gency,
<br />
<br />.viii your establishment be served by:
<br />
<br />'I. Septic tank system7 0 Yes
<br />1 Packagesewerplant7 DYes
<br />~ r'l'unicipal[utility seVier? IIlYes
<br />
<br />'Dlj M.Pc;-r~
<br />
<br />Waste water from cleaning containers disposed on site?
<br />
<br />[] Yes
<br />
<br />o No
<br />
<br />""~-
<br />
<br />m Will establishment have an Alcoholic Beverage license?
<br />
<br />DYes ~No
<br />
<br />PAY TO THE /....., V ( J _
<br />ORDE. R, ,OF ...L/ I J.-=> ill air- II/) r,;: / . '.;7'
<br />. , \ .,. I " - c. S Ntff) ;(b<:~~'
<br />=.....'evQ.(\-ey,r:,V.J.<<:I!:F_,/V,.., . ' URCHASERS3 NI'G.V '"OT'..
<br />j- ~ YV~c __ " TER'f>i3'1:AEV~Sf/S':6E c .,
<br />
<br />IS$I}I!d by Int+,;qrJl~rl i1J"mt!llf i"' ~, _ AUT .J n71. E , "
<br />'.... --=.ss::--:->:-,",'~: '., ~y..~~=s, III" 'P1'..,.. ':"'''' r:IJ'~Uh",M ~'~"" ,1""-'''"1 [lIIWIII".-..",. l~n,," J"I'C:"'~C"::,~~, REPRESEr. r" TIV[
<br />
<br />
<br />I: .0 2 .00 ~ 00': ~ 0 0 b . -g-S -9 O~2~S'Q'~,~;'.":'"-~-'"-._-- '"-. ., _ ,;,_~~,.~~_=~__
<br />
<br />DNa
<br />DNo
<br />DNo
<br />
<br />~
<br />~,
<br />I' (i~~~N?' I(~[[y
<br />
<br />I,
<br />r
<br />r you iJnsIVcred YES to item B or C, compIete the lollowinr
<br />
<br />'lame of municipal/utility agency
<br />
<br />ell'{ op
<br />
<br />;ileof grease trap \lSO gal. location
<br />
<br />Vater Supply, Prior to the opening inspection, lhe applica
<br />or a pOlable water supply from the appropriate agency {
<br />J~partment of Environmental Protection, municipality or s I!
<br />nay be a copy of a utility bill, a receipt or permit, or a lelt
<br />
<br />'/ill your establishment be served by:
<br />
<br />l On,sitcwaterwell? DYes
<br />l, Municipal/utilitywater7 ~Yes
<br />
<br />PAY EXACTLY
<br />
<br />DNa
<br />DNa
<br />
<br />, you Jnswered YES 10 item 0, complete lh~ following:
<br />
<br />'ame of municipal/utility agency
<br />
<br />c rf"'i
<br />
<br />OF :Z5PHY~HfLL~
<br />
<br />~'~
<br />SIGNATURE OF APPLICANT
<br />
<br />
<br />I I
<br />
<br />Form HR 5Q21,010 (Formerly BPR 21,010)
<br />
<br />. I :.
<br />
<br />. r.l.....'..."""r...'''''ll~~ll~~nt
<br />
<br />J1IJ1@I0JJEYf @~~~.
<br />06-196903250
<br />
<br />::i!'
<br />
<br />
<br />82,40/10,1
<br />
<br />
<br />-"
<br />
<br />
<br />...." -'
<br />
<br />~6~
<br />
<br />ie/ob 100
<br />,r-.,lDNfH DAY YEAR
<br />
<br />
<br />R,',"!i11999 Nt::9
<br />
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