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<br /> <br />CHARLES H. BRONSON <br />COMMISSIONER <br /> <br />'Florida Department of Agriculture and Consumer Services <br />Division of Food Safety <br /> <br />-......,i <br /> <br />ANNUAL FOOD PERMIT APPLICATION <br /> <br />F.S, Chapter 500 <br />(850) 245-5520 <br /> <br />Print Date: September 12, 2005 <br /> <br />11111...111111111111111111111111111111 <br /> <br />Visit# 2645-1796-0000-38 <br />Bureau of Food and Meat Inspection <br />Attention: Records Section <br />3125 Conner Boulevard, C-26 <br />Tallahassee, Florida 32399-1650 <br /> <br />Note: Inspection by the Department is required prior to submission of this application. <br /> <br />The Department of Agriculture and Consumer Services is the exclusive regulatory and permitting authority for any person, busmess or <br />corporation engaged in manufacturing, processing, packing, holding or preparing food or selling food at wholesale or retail. For purposes <br />of this application, food is ronsidered to include, but is not limited to, all prepackaged grocery items, prepared foods, packaged ice, bottled <br />or vended water, candy and other snack foods, soda, infant formula, vitamin and mineral dietary supplements. <br /> <br />INFORMATION ABOUT THE LOCATION TO BE PERMITIED <br /> <br />~ <br /> <br />Finn Number 26451786900038 <br /> <br />Finn Type 141 <br /> <br />Territory 706 <br /> <br />Established Date 09/12/2005 <br /> <br />( ) Renewal 90 New Business () Corrected Information () Other: <br /> <br />Business Name <br />Type Description <br />Location Address <br />City/State/Zip <br />Phone Number <br />Directions <br /> <br />Do you manufacture and package ice or bottle water for sale? ( )Yes ( )No. If Yes: Thefollowing information must be submitted with the <br />application: 1. Indicate source(s) of water used. 2. Indicate any treatment provided to the ice prior to packaging, <br /> <br />HOLE IN ONE DONUT SHOP #3 <br />RETAIL BAKERY WIFS <br />14837 N FLORIDA AVE <br />TAMPA, FL 33613-1825 <br />(813) 963-6207 Ext, <br /> <br />County HILLSBOROUGH <br /> <br />INFORMATION ABOUT THE OWNER <br /> <br />~ <br /> <br />Name of Owner <br />Business Type <br />Phone Number <br />Mailing Address <br />City/State/Zip <br />E-Mail <br />Federal Employers ID# (FEIN) <br />Sales Tax # <br /> <br />AN PUM <br />SOLE PROPRIETOR <br />(813) 963-6207 Ext, <br />14837 N FLORIDA AVE <br />TAMPA, FL 33613-1825 <br /> <br />39-80-133939-36 <br /> <br />This application must be signed by the applicant, owner or chief executive of the applicant, without the need for witnesses. If a <br />corporation is in the hands of a receiver or trustee, this application shall be executed on behalf of the corporation by the receiver or <br />trustee. I certify that I am empowered to execute this application as required by Chapter 500, Florida Statutes, <br /> <br />Print Name of Applicant A N J:: u M <br /> <br />Signature Cl/ -e VAA- <br /> <br />DACS-14306 (IN-63) Rev, 6/03 <br /> <br />Title () L() A.] -t--tL <br />Date q-I d- - (!J ,~ <br /> <br />Page 1 <br /> <br />EIS03030 <br />