20090909072339996.pdfDate:,
Food Section
Snohomish Health District
341241 Rucker Ave., Suite 1414
Everett, WA 8201-3900
Restroom leiter for: bb ve. 6s ra-ssq-o
([dame of Food Stand Concession or Mobile Food. Vebiele)
1, mrar-kis 6,v t have an agreement with C14 t+^a o,ncis C 5�-Q rani P,"
(Owner name of Restroom facility) (Owner name of Food Stand/Mobile)
giving Csov"'S o and his/her employees the right to use the restrooms at
Name of Food Stara /Mobile)
2'3c P 99, moods VVA 92.0 Z(, J add s Cen taz6
(fume and address of Restroom facility)
The hours that I allow the restroom to be used are: c3 awv r Lryl
These hours are during tray normal operating hours.
[_]These hours are outside my normal operating hours. l have provided after hours access.
This agreement begins 6/tom r/ra9' . 1 am not responsible for any actions of '�' �Z, Nc, Es C, 0
ate. (Name of Food Stand/Mobile)
outside of my establishment and may terminate nay agreement with Uj4MOnd s A
(Name of Food Stand/Mobile)
for 4 > d S, 6, ) Nxm.+2�t'1..
Reason for termination of agreement)
I understand that Snohomish health District has the right to insl)ect the restroom while the restroom is
in oj)eration.
I will notify Snohomish Health District at such time as the agreement is terminated,.
Signed: bate: �o/a:. Lo
froom 0wa
(Consull your a tornek before, signing anjA legal eloeunteut)
urifFy`�
Rev32l 08h—
Environmental health Division
Food Section
3020 Rucker Avenue
Everett„ WA 98201
425.339.5250 FAX:425.339,5254