20180612103028.pdfCITY OF EDMONDS
I2I 5TH AVENUENORTH. EDMONDS, V/A 98020
PHONE: (425)771-0220 - FAX: (425)771-0221
Monday, June 11,2018
Your request for a Development Review Committee meeting has been accepted by the City of &lmonds. The meeting
is scheduled for:0612112018 at 3:00 PM . We Strongþ suggest that all lead design professionals associated with the
project attend this meeting.
App lication Number: DRC20 I 8001 9
PROP OWNER:DEBBIEEV/ING
IOO5 CASCADELANE
EDMONDS, WA 98026
(206) 61 8-0606
Project Address:525 MAIN ST, EDMONDS
kis ting Us e/ Occupancy:
EMPTY TENANT SPACE V/A S INSURANCE OFFICE
Proposed Project:
PROPOSED- RESTAURANT.
To view up to rlate informntion about your permiÍ please vìsit the CÍty of Edmowls Development Services website
at http : //www. c i. e dmo nd s.w a. us.
D B\'BLOPMENT REVTEW APPLICATION ACCBPTAN CE
858
PRE-APPLICATION MEETI NG
SUBMITTAL REQUIRMENTS
PËßMIT]1NG &'][VÊLOPMËNT
1?1 5th Avenue N
F:425.771.Q22A
OPTION 1
N FORMAL PRE-APPL¡CATION MEET¡NG
(SEE BACK PAGE)
51,000.00 (1/2will be applied toward thefuture
permit submittal)
Staff from the Building, Planning, Engineering and
Fire Departments attend the meeting , provÍde written
comments and answer quest¡ons regarding the
proposed project. This meeting is encouraged for
major projects prior to a formal application submittal
to the City. The goal is to identify MAJOR issues and
discuss processing procedures applicable to the
project.
Submit 1 set of plans with reouired information per
page 2.
NOTE: PRE-APP Meetings are scheduled for the next
available date with a minimum of fwoweeks lead
time & DRC Meetings a minimum of one week.
Zonino: Lot Size: Sno\County
\ oPTtoN 2
\ü DEVELopMENT RËvrËw coMMtrrEE MEETTNG
Complementary, informal meeting
This is an informal opportunity to meet with staff
and discuss your preliminary ideas and concepts
for a project. The intent is to help identify the
major code requirements that will need to be
addressed and any significant site development
issues that may relate to the project. The intent is
for this to occur prior to considerable investment
in plans and/or design work. You may wish to
have your design professional(s) accompany you.
Submit 1 set of the following:
1) Site Plan
2) Vicinity Map
3) This completed form
4) Pertinent background information
5) Floor plans if applicable
6) List of questions regarding your proposed project
COMPLETE ALL REQUESTED IN FORMATION
Tax Account #
å W*Site Address(s):
Existing Use/Occupancy:
Pre-Submittal for:I t-and Use Approval/ Permit
Description of Project:
bcz_
Meetings are held on Thursdays at 1:30 and 3:00 p.m. for approximately
45 minutes.
Requests are scheduled on a first come basis in person at the permit
counter and which have completed all requested information.
IÞwt,^Aonlicant/ Contact:
Ve - v.3 Fo''z tg Z-r,r
Mailing
\ -l-l Address:rt L 6-}^ .*1,/4 \^J
ëh l^/14
zip:1tro37
Phone:
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Revised on 01/04/2017
\ Building Perm¡t only
ô
Poge 7 of 2
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PRE-APPLICATION M EET¡ NG
SUBMITTAL REQUIRMENTS
PTRMITI-ING & DñVEtÛPMËNT
1?-1 5fh Avenue N
F:425.77'1.0220
All major projects are highly encouraged to schedule a formal Pre-Application Meeting with the
Development services Department prior to making a formal application submittal to the City. The goal
of the meeting is to identify MAJOR issues and proiessing procedures applicable to the project which
ì
are helpful for an applicaníto determine feasibility, desigï i¡.s.ues, tim¡ng, and various processes required
ioi. óio¡ã.t. The fåe is 51,000.00, but one half of ih¡s fee will be applied toward the future permit
submittal.
A pre-Applicat¡on Meeting is Not a Permit Application Submittal.
Pre-application meet¡ngs are held on
Thursdays at 1:30 & 3:00 p.m. To make an
appointment, bring 1 set of folded plans with
pert¡nent information and the required fee to
ihe Development Services Department (2nd
Floor City Hall, 121 Sth Ave N).
Staff from the Building, Planning, Engineering,
and Fire Departments' attend the meeting,
provide written comments and answer
questions regarding the Project.
OpTtON I SUBMTTTAL REQUIREMËNTS: PROVIDE THE FOLLOWING INFORMATION
ONPLANSANDSUBMITWITHMEËTINGREQUESTFORM:
Meetings are held on Thursdays at 1:30 and 3:00 p.m. for approximately
45 minutes.
Requests are scheduled on a first come basis in person at the permit
counter and which have completed all requested information.
General lnformation:
¡ Assessor's tax parcel number(s) for all lots
o Site address(es)
o Existing and proposed occupancy(ies) and uses
o Building type of construction (e'9. VB, VA, lllB)
o Number of stories
o Zoning designation
o Number of dwelling units
. Floor areas of each floor of the building
o Fire sprinkler system and fire alarm system types
o Lot area
Site/Utility Plan:
r Site drawings to scale (prefer 1" =20'). Location/vicinitymaP
o North arrow
o Existing and proposed structures, and dimensioned
distances from ProPertY lines
o For subdivisions: proposed lot configuration, lot
sizes, lot dimensions, existing and proposed access
easements, existing and proposed points of access,
existing and proposed ri ghts-of-way
Site/Utility Plan, continued:
r Building address number(s)
o Topography at 5 foot or 2 foot intervals
o Trash enclosure location and orientation
. Streets/alleys
o Easements (utility, access, etc.)
r Exísting and proposed síte access
. Parking layout, typical stall dimensions, accessible
parking and route of travel, drive aisles noted as one-
way and/or two way
o Landscaped areas and signage
o Water courses and drainage patterns
o Location of mechanical/electrical equipment,
transformers, generators, vaults, etc-
¡ Location of existing and proposed utilities (sewer,
storm, water, Power, etc.)
Floor Plans:
r Existing and proposed floor plans (preferred scale 7¿"
= 1') sliowing uses, exiting, restrooms, and accessible
route of travèl, all existing and proposed buildíng
openings including windows/doors, etc.
Revised on 01/04/2017 Page 2 of 2
tu
STORAGE
Z+SÏORAGE
'¿
r
I
I
36'- NO
CLOSER
I
z
CTEAR SPACE
REQ'D
ItIt
PrE Stand
85odû:ur¡61-
Table
39" x 24"
J{
Sirk
Cooþr
t7
Hand
$nk
.(Grease Tr4 below)ne$,15/8" med
44'REQ'D EXIT PATH
KTTCHEN / BAR - 302 SF (2 oCC)
r---
Hand
16'SS
---_\
48"x¡18'REQ'D I
CLEARSPACE I
I
I
PUBLIC SEATING AREA - 386 SF
(26 OCC)
,
*r,tbrvlÇ9;u'rvt ?-
Fence
adjacent
building
8" CMU wall
existing
roof
ALLEY - paved
60,00' property line (tyP,)
asphalt paving (existing to remain)
sidewalk (existing)
curbside parking -
existing to remain
adjacent
building
adjacent
building
OqÕ
ENCLOSED DECK
- N,r.c,
.-t..rLr."-J
V^er-vvt
--"-='
f*n(
existing
restaurant
tenant
q
MAIN STREET
g
scale: 1"=10'
MAIZE & BARLEY SITE UTILITY PLAN:
-Site address: 525 Main St, Edmonds WA 98020
-Proposed use, small counter service restaurant serving beer and wine. Approximately
28 pp capacity including staff.
-1 story
-Retail zoning
-Trash will be located in back alley west of enclosed deck noted on submission 2*
Access through West storage unit for deliveries, trash and recycling removal.
-Awaiting response from PSE for assigned project coordinator for a gas connection via
existing hook up in alley North of project site. Plan is to run gas line overhead building
-Street parking, deliveries via West Storage unit noted in submission 1*
-Will replace plastic sign within pre-existing "Farmers Insurance" duralight frame.
-Electrical panel noted (handwritten) on submission 2*
-Water meter will be split from current meter #75213994
Will submit updated complete plans from architect prior to meeting.
Should address: Easements, utility access, water courses and/or drainage
Questions: seeking general feedback.
SNOHOMISH
HEALTH DISTRICT
WWW.SNOHD,ORG
rÑtı'514
Sgóó5-lrqs s'"
General Food Plan Review Application
Application must be completed iy[p!!and submitted wlth fee and the items listed for processing:
Reviewed for compleleness by EHS lnitials
PLAN REVIEW
$500 IPE 5672) plus $1 85 per hour after 2 hours New food service establishment
! $t gS Base fee plus $1 85 per hour for each add'l
hour over t hour (PE 5685)
I gS¡S Base fee plus $185 per hour for each add'l
hour (PE 5685 & 5642)
E $tes eE 5682) per inspection
n $tas PE s67o)
185 olus lab 568s)
n SSOo Base fee olus $185 for each add'l permit
(PE 5676 & 5675)
! gtas PEs67T)
NT INFORMATION
Name
'aJs
ER
tla
Remodel of existing food service establishment or revision of approved
plan
Change of ownership / conditional operating permìt AND remodel of
existing food service establishment or revision of approved plan
Reopen former food service establishment
New Limited Grocery, Tap Room / Tasting Room
HACCP * when required by WAC for menu items
New multiple permit food service establishment (large grocery store)
Plan review consultation (On and/or off site)
ZlP:
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different than
Phone
Address:
OTI{ER INFORMATION
of Food Service Establishment:
Local o&
Wâter D¡strict:Private Well Public
District:Sewer Onsite
lnspection is based upon requirements of WAC 246-215: Rules & Regulations of the State Board of Health for Food Service
Senitation. Other agency requisito io your operation may include County or Planning, Building, Pl umbing and Fire
W and
stc
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hoxrt k-te ê
E-mail Address:a-'è
State' \A/'A
State:
tu,.o.^-JS Wate¡ Suoolv (check one):
lr" ¡-rlc Sewaoe Disoosal lcheck oneÈ
Environmentql Hesllh Division
3020 Rucker Avenue, Suite 104 r Evereit, WA 98201-3900 r fox: 425.339.5254 r tel: 425.339.5250
EGE[VED
JUN t) 6 2Û18m*Æ
Vì4"
SNOHOMISH
HEALTH DISTRICT
WWW.SNOHD,ORG N ew Restau ra"f fi!åffi 8ËïlA w Ch ec kt i st
Facility name Sz( l*ra,,^ -'' É J,*r.-^ i =
ol&¡t ct
This checklist will help you prepare a complete plan review packet. Submit the completed plan review packet and checklist
with the required appiication fee. lncomplete plan review packets will not be accepted. Make a copy of this plan review
packet for your records prior to submittal. Plan review fees are non-refundable.
ITEM Office
Use Only
lntake
u 1 Application Provide comptete Food Plan Review appllcation.
ñ
2 Water and
sewer
adequacy
Provide proof that the facility is connected to an approved water and sewer or
septic system,
r/¿-lt? t1 zs l1 1 .Ô Z1 I
,ll'tN2{r" \¡r¡t.ir \''!r'r r,n *J tt , '" "
ñ J Plan review
questionnaire
Provide complete Plan Review Questionnaire form.
.M 4 Floor plan Provide a floor plan of the entire facility. Floor plan must show location of all
equipment (sinks, refrigeration, cooking, hoods, blenders, countertop appliances, etc.),
reilrooms, storage areas, etc. Floor plan must be no smaller than % equals 1'.
5 Equipment list Provide make and model numbers of all equipment (including countertop
appliances). Show location on floor plan' For remodels bolh new and existing
equipment must be shown on the floor plan. Only commercial grade, National
Sanitation Foundation (NSF) or equivalent equipment is acceptable.
u o Finish
schedule
Provide the mater¡als used for all floors, walls, ceilings, counters, and cabinets.
t 7 Menus Provide a detailed menu of all the food and beverages you will be serving or a list
of food and beverages you will be selling. lnclude condiments, iced beverages and
baked goods. Be sure to include specials and seasonal items. Only food and beverages
listed may be served. All breakfast, dinner, lunch, bar/lounge, happy hour, k¡ds,
catering, and online menus must be submitted.r I Food sources Provide a llst of all food and beverage suppliers.
ñ
I Food
preparation
steps
Provide a description of how all menu items will be prepared.
M 10 Waste disposal Provide complete Waste Disposal form.
E 11 Supplemental
questions
Provide complete Supplemental Question form(s) if applicable.
(catering and food processing)
ñ 12 Fee lnclude application fee,
I understand I cannot open this food establ nt until I have received written approval from this program, obtained all
annual operating ndh approved by all applicable city, county and state
Signature/Title Date V
Environmenlol Heolth Division
3020 Rucker Avenue, Suite I04 r Everett, WA 98201-3900 r fox: 425.339.5254 r tel: 425.339.5250
SNOHOMISH
HEALTH DISTRICT
WWW.SNOHD.ORG Water and Sewer / Food &
Facility name:
Site address:Sz{ Ma i". gl
{
City:
Parcel number:Proposed number of seats:
Contact name:V¿ ^'^s ?u.tk:¿-at Phone:g 6 201ü
rmail:lM4iu ¿- q f;¡¡^4
Fax:-?åfrl"s5llì.'\
D New construction N,Remodel/Alteration E Expansion of existing restaurant
u yes\ lr¡o ls the facility connected to a septic system?
--Ut Yes E No Are public restrooms available?
\-Q Yes O No ls a grease trap required by sewer district or building department?
É. J"-onJs state{ft-ztP' R8O2Õ
"",.'8,^.^'LJ;
ÉGErvÉED
I
IJ't^,À rR-s{^*,"-a^d_Describe the proposed Proj
ê-
Sewage system\€l Sewer bill or availability letter attached tr Below completed by official
This section should be completed by a Public Sewer System Official, if a sewer bill or availability letter is not
provided.
Name of system Sewer utility:
The above system will provide service to the facility listed at the above addréss
System official:Phone Date
Water system -g Water bill or availability letter attached El Below completed by official
This section should be completed by a Public Water System Official, if a water bill or availability letter is not
provided.
Name of system:
\
The above facility \El is connected E has applied
The above system will provide service to the facility listed at the above address
System official:Phone:Dater
State lD number:
Environmentol Heqllh Divislon
3020 Rucker Avenue, Suile .l04 I Everelt, WA 9820ì -3900 r fox: 425.339.5254 r tel: 425,339,5250
SNOHOMISH
HEALTH DISTRICT
WWW.SNOHD.ORG PIan Review Questionnaire
Facility Name 121- q ^) T:-,rt
1 t--": I'
tu^ \"¿ "'+-L C'Jf{,2 c-Q* -
2. How many meals do you anticipate serving per day?
3. How many times per week do you anticipate delivery of food?Zuru o 6 ?t1B
4. How many times per week do you anticipate delivery of dry goods?gna¡o$i?!^,
-.{êã[flT ut¡¡r¡tr".\
5, E Yes'E No Will you offer catering? lf yes, complete the catering questionnaire.
6. n v"òg No Will you offer off-site food delivery?
7. -Et Yes tr No Willalcoholic beverages be served? (include on menu)
8. \GlYes Q No ls there customer seating inside the facility?
How many seats are in the facility, including the bar and lounge?
g. O Yes'Ð No ls there customer seating outside the facility? How many seats are outside?
1ì\!l Yes B No U N/A lf you have customer seating, is your restroom accessible to customers without
passing through food preparation, food storage and/or scullery areas?
11. tl Yes bJNo Do you have to go outside to access any walk-in refrigeration/freezers, food storage,
equipment, and cooking or preparation areas? All locations must be clearly marked on floor plans.
12. Where will chemicals such as cleaning products be stored?
N¿v i t, 1\. F^S r',..,k--âv,\ A sl"e. t4
13. Where will employee belongings be stored?\ o cW-, oVouu L^o^J t-^L
Envlronmentol Heollh Division
3020 Rucker Avenue, Suite ì 04 r Everett, WA 9820t -3900 r fox: 42533? .5254 r tel: 425.339.5250
tìb Yes U trto ls all lighting above food preparation, storage and service areas shatterproof or covered?
(Required)
15. tr YesE No Will any food be self-service? lf yes, list foods and how you will prevent contamination:
tf
JUN () 6 ?II1B
16. B yes tr No Are allfood and single-service items protected from .yrtgÈ&lntt?iÅf,fië¿lation by a sneeze
guard? This includes self-servìce qorldiment bars, salad bars, buffet linèS1ëSprèsso counters and all
ıtherfood preparation areas, \ü/A
t Zþ Ves tr No Are handwash sinks located at all cook lines, food preparation and service areas, and
dishwashing areas?
13¡fi Yes tr No ls a 3-compartment sink with attached drainboards on both sides provided? (Required)
ih*ú Yes tr No ls each basin of the 3-compartment sink large enough to submerge and wash all
equipment?
)Ù.-b Yes E No Do all sinks, including 3-compartment sinks, and food preparation sinks have basins with
rounded corners? (Required)
21þ Yes tl No Can you completely fill two compartments of lhe 3-compartment sink with hot water and
provide hot water af all handwash sinks without the temperature dropping below 100'F? (Required)
2àrÐ Yes D No E¡ N/A Are indirect drains (i.e. air gap) provided for all food preparation sinks,
dishwashers, ice machines, soda dispensers, steam tables, woks, dipper wells, espresso machines,
beer tap drip trays, walk-in refrigeration/freezers, and all equipment in which food or food contact
equipment is placed? (Buckets are not allowed)
Z31Q Yes t1 No Does your menu include fresh fruit and vegetable items, such as lemons, limes, onions,
tomatoes, potatoes, lettuce or berries?
24. b yes O No n N/A lf your menu includes fresh fruit and vegetable items, is an indirectly drained food
preparation sink with an integral drainboard provided? (Required)
\
25. A YeÞEl No Will you prepare, rinse or thaw under running water, raw meat, poultry, and or seafood?
lf yes, list:
26. tr Yes ü Nì\ ruin f raw meat, poultry, or seafood are prepared, rinsed or thawed under running
water, is a second indirectly drained food preparation sink with ari integral drainboard provided?
(Required. Sinks with multiple compartments may not be used for both produce and raw meat prep.)
Environmentol Heollh Dlvlslon
3020 Rucker Avenue, Suile .l04 r Everett, WA 9820t -3900 r fox: 425.339.5254 r tel: 425.339.5250
zz\É yes n uo ls at least 16" of separation or proper barriers 16" tall provided between all food
preparation sinks and any source of contamination?
z\p yes o No ls at least 16" of separation or proper barriers provided between all produce preparation
sinks and raw meat, poultry, and or seafood?
zilu ves E No Are 16" high splash guards installed between all sinks that are less than 16" apart?
g}¡p Ves tr No Are soap and paper towel dispensers installed inside the splash guard area at all
handwash sink locations?
gl.ú y", tr No Are all handwash sink basins at least 10" long by 10" wide and 5" deep? (Required)
32. tr Yes Ú No Do you have a designated mop sink? (Required)
33. tr Yes tl No ls the mop sink located so food and equipment are not contaminated when used?
34. tr Yes 0 No Does the mop sink have a vacuum breaker installed?
35. B yes þ No WiU a chemical dispensing system be installed at the mop sink?
36. n yes D No til, Nin lf a soda fountain system is used, is a reduced pressure backflow assembly
(RPBA) installed and tested?
\
37. D yes a No\ N/A lf a soda fountain system is used, are all pipes and fittings used downstream of
the reduced pr"rrur* backflow assemntyiRPBA)non-corrodible? (copper or brass are prohibited)
gfu yes n No ls all equipment commercial grade, NSF certified or equivalent? (Required)
39. tr yebe No Will any food be stored or prepared at another location? lf yes, list name and address
where food will be stored or prepared:
D EIVÉ
ilrñ 06 2t110
Sno homis h
\
40. tr yes &¡lo W¡¡ any food be cooked or hot held unattended (i.e. overnight or more than 2 hours of
unattended coot<ing)Z lf yes, the questionnaire for cooked or unattended food must be completed'
\
41. tr yesÞNo Will there be any cooking or food preparation outside the establishment? All locations
must be clearly marked on floor plans'
42. g1 ye\! No Will any food of animal origin be undercooked at the customer's request, such as steaks,
eggs, or hamburger? lf Yes, list:
Environmenlol Heolth Division
3020 Rucker Avenue, Suìle t 04 r Everett, WA gS2O l -39OO r fox: 425.339. 5254 r tel: 425'33?'5250
43. D Ye$¡ No Will any fish or seafood be served raw or undercooked? lf yes, list
\
44. D yes tr No\ N/A lf fish or seafood will be served raw or undercooked, is proper parasite
destruction documentation submitted?
aS. U ye$ No Will any menu items include wild mushrooms? lf yes, the wild mushroom questionnaire
must be completed.
46. tr Yes El No Will any food be smoked as a method of food preservation rather than flavor
enhancement? (Used to preserve or change a food so it no longer requires refrlgeration) lf yes, you
must submit the food preparation steps foi all the smoked foods along with laboratory documentation of
shelf stability for each food item.
47. tr Yes Emo W¡lt any food be cured? lf yes, the food preparation steps for all the cured foods must be
submitted.
48. D Yes-El No Will any food additives be used to preserve or change a food so it no longer needs to be
refrigeraìed? lf yes, the food preparation steps for all these foods along with laboratory documentation of
shelf stability must be submitted for each food item.
a9. n Ye\H No Will a display tank be used for molluscan shellfish, such as oysters or clams? lf yes,
submit àOO¡t¡onal informatión as noted in the Molluscan Shellfish Tank questionnaire.
\
SO. L¡ Yekl No Will custom processing of animals be offered for a customer's personal use as food (i'e.
deer) aàd not for sale or service in a food establishment? lf yes, submit the food preparation steps
including how custom processed foods will be kept separated from all other foods during receiving,
processing, storage and handling.
51. D Yes El No Will any food be grown specifically for sale or service in the food establishment such as
sprouts? lf yes, the growing and food preparation steps for all these food items must be submitted'
52. tr Yes g t¡o Willanyfood be vacuum packaged or reduced oxygen packaged? lf yes, submit
additional information as noted in the Vacuum Packaging-Reduced Oxygen Packaging questionnaire.
53. tr Yes Q No Will any food be cook-chill or sous vide ? lf yes, submit additional information as noted in
the cook-chill or sous vide questionnaire.
lf you answered yes to questions 44-51, include the proper food preparation process descriptions and
variance request.
0 6 2i!1ß
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Environmenlol Heqllh Division
3020 Rucker Avenue, Suite 104 r Everetl, WA 98201-3900 r fox: 425.339.5254 r lel: 425'339'5250
È
Phone: 440-365-1 399
Toll Free Ph: 800-71 5-1014
www.hoodmart.com
sales(Ahoodmart.com
Fax: 440-365-2368
Toll Free Faxi 800-716-1214
JUN O 6 ztlIü
Snohomish
Heatth District
TotalAmount: $5'383'53
172 Reaser Court
Elyria, OH 44035
PO Number:
Bill To Name:
Bill To:
Lynnwood, WA
98037
Phone:
TeTMg: PREPA¡D OR CREOIT CARD
24857
61112018
Michelle
A
Lynnwood, WA
s8037
kjeldsa@gmail,com
EGEilVED
A Kjeldsen
Ouote Number:
Quote Date:
Sales ReP:
Ship to Name:
Ship To:
Email
optlonal ltems (Not lncluded ln Total}: El€ctrlcal control Box wllh Duct Thormoslat. Add $755 to Total; Gr€486 Extractor for Exhaust
Fan-Add$S2toTotal;4,xS4.,HsSBaGkwallPanels(wlthseamg/Ends).Add$260toTotal
X 48" Hybrid (S/S Front and Ends) Box Make-Up Air lncludlng 3" Air
on Back and Brackets
Hood with Short-Cycle
.00
xl6nx F¡lter
Globewlth.00
762UL LISTEDl11HP0PHASE,SINGLE1FAN5V1EXHAUSTDRIVEDIRECT10D1.00
Curb lor1.00
AMP VARIABLE SPEED CONTROL for 10D, 20D & 28DSPEEÞ
AMP
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AIr FAN - FLATCurb for- Flat1.00
OeteclionNozzles,Conduit,Plpe,lncludes:Fire SystemSuppresslonPre-Piped off ControlShutValve,GasStationPullRemotetoSwitch,MìcroAffixedHood,
FinalP€rmits,Test)HookFinallncludeNOTandTanks(ÐoesBrackets
FIRE SYSTEM 4'
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conditionsofsale;AllpficequotesafeValidforthirty(30)daysfromtheabovedate'ALLSALESAREFlNAL.ordefchangesafter4Ehours
rnay be subiect to a tee. All ¡nstallation, electf¡cal, roofing, ducting, construction, and arch¡tectulal work as well as pefmit lêes' stalnless steel
wallpanelsand/orshrouds,ductenclosufes,firewrap,firesyslemconnecììon,andtest¡ngareNoTlNcLUDEDunlessspecifiedinwriting
abovs Buyet respong¡ble for compliance with local regulations inctudlng but not limited to clearance to combustlble materials requiremenls
seller wlLL Nor be liable for any consequential or indirect damages. ihis agreement is subject to ohio law Your signature below
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SNOHOMISH
HEALTH DISTRICT IRìEGEIVED Finish Schedule
WWW.SNOHD.ORG
Facility name:
Hea Di
Provide the materials used for allfloors, walls, coving and ceilings'
. All bare wood surfaces (doors, trim, counters, shelves, cabinets, etc') must be painted or sealed'
. Floors must be construited of light colored, smooth, easily cleanable, non-absorbent material' Expansion
joints, seams, saw cuts and the-like in conórete floors in all areas, including customer seating areas, must
'be filled and sealed so as to provide a smooth and cleanable surface'
. Coving must be installed at all wall/floor junctions.
. Walls must be constructed of light colored, smooth, easily cleanable, non-absorbent materials' Provide
Fiber Reinforced plastic (FRP)Ihminate plastic, tile, or similar waterproof material on wall surfaces behind
sinks, dishwashers, food'preparation areas, and areas exposed to moisture'
. Ceilings above tne t<itcfren, låunge, wait and service areas must be constructed of light colored, smooth,
easilyîleanable, non-absorbent-materials. Unsealed and or perforated acoustical ceiling tiles are not
allowed, Vinyl covered ceiling tiles such as vinyl rock or other washable surfaces are allowed.
. All lighting over food prepara-tion, handling and storage areas must have covers or shatterproof bulbs'
Sample finish schedule
Floors Coving Walls Ceiling Counters
Kitchen vinyltile 6" rubber base FRP painted gypsum board laminate
Wait area vinvltile 4" rubber base painted gvpsum board vinyl rock laminate
Lounqe sealed canerete 4" rubber base varnished wood Armstrong VL tiles qranite
Dininq area carpet 4" rubber base nainted qvPsum board painted gyqsum board n/a
Bathrooms ceramic tile ceramic tíle oainted qvpsum board paînted gvpsum board
woodsfee/Refr andShelvinq
are sha All kitchen have covers,Liohtinq Bar I'
Finish schedule
û lncluded on floor Plans
Floors Coving Walls Ceiling Counters
Kitchen L¿e ù .l.c :' ¡ ,i. ( iJJ {
u{/ 4'::çi ';?Cei^ttt', t'!<ccÇ,,.,.c L,,l r-
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Shelving l
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Environmentsl Heolth Division
3020 Rucker Avenue, suiTe I04 r Everett. wA 98201-3900 I fox: 425.339.5254 r tel: 425.339.5254
SNOHOMISH
HEALTH DISTRICT Ve-r",..r,Menu
WWW-SNOHD.ORG
provide copies of your menus. lnclude all food and beverages you will serve. lf the facility is a grocery store
serving only fruits,-vegeiables or commercially prepackaged food, a list of goods sold may be sY-bmitted in .
ptace ıf thé menu. Bãsure to include specialð and seasonal items. Only food and beverages listed may be
served, Submit copies of all breakfast, dinner, lunch, bar/lounge, happy hour, kids, catering, and online
menusr fresh sheeìs, table tops or menu boards. lf a menu board will be used, provide photographs of the
menu s'howing allfood and beverages listed. All menu items must be readable in photographs-
A consumer advisory is required for allfood of animal origin that is offered raw, undercooked or cooked to
the customer's specification. Be sure all menu items requiring a consumer advisory are clearly identified and
remind the patroh that consuming these foods may result in foodborne illness. Consumer Advisory information
may be found at Washinqton State Department of Health under Code Clarifications.
The menu, food preparation steps, and the mode of operation may be restricted to protect public health (WAC
246-215).
Sample Menu
Breakfast
Pancakes....
Eggs*, hash browns, bacon, toast
Oatmeal......
Lunch
Ham sandwich.............
Pho soup*...
Rib eye steak*
Dinner
Prime rib*.....
Shrimp pasta
Deluxe cheeseburger*
Chicken sa|ad.............
AAA #1 Drive ln IRìEGEIVED
JUN O 6 2O1B
Snohontish
Health Dishict
... $2.00
$3,00
$2.00
........... $3.00
"""""' $3'00
..........$10.00
....$10.00
....$10.00
....$10.00
....$10.00
Salads
Mixed greens........
Romaine.,...
Caesar".......
Beverages
Fountain beverages
Lar9e..........
Medium.....
Small...
.....$s.oo
..... $3.00
.....$3.00
$3.00
$2.00
$1.00
$1.00
$1.00
* These menu items are served raw, undercooked or cooked to your specification,
Consuming raw or undercooked food may increase your risk of foodborne illness.
Environmentol Heqlth Division
3020 Rucker Avenue, Suile ,l04 r Everett, WA 9820I -3900 r fqx: 425.339.5254 J tel: 425.339.8730
f-è
æ
SNOHOMISH
HEALTH DISTRICT Food Sources
WWW.SNOHD.ORG
List ail food and beverage suppliers you use. Please check the boxes of the common suppliers you use and
add the name and phoneiumber of any of your suppliers that are not already listed'
This list is provided for informational pr"rrposes only'ånd for the convenience of the r"tser. This should not be
taken as an endorsem"Át ny ttre snorromish Healih Dístrict. This is not a contplete list of available suppliers'
Look in the Yellow Pages or similar references for additional suppliers'
Name of supPlier Phone number
Facility name:
tl
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tr
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Boyd's Coffee
Cash N Carry (Everett)
Charlie's Produce
Coke
Costco (Everett)
Costco Business Center (Lynnwood)
Food Services of America
Franz Bakery
Pepsi
Restaurant DePot (Woodinville)
Sam's Club
Sunfood Trading
Sysco
e Dç 4--Õ B-Sr, u*{-Izç-buto.\*laa¡
¿- e--2pb, U?-ç, \14\?*
800.545.4077
425.339.2628
206.625.1412
800.647.2653
425.37s.745itÐ)
42s.640.770!ilú
425.251.9100
206.682.2244
425.355.2212
425.483.5600
206.362.6700
206.682.8823
206.721.1777
EGEIVED
JUN O 6 2T1B
Snohomish
Health Diskict
z.-\ /^'.U-¡-'t¡ i,".,-' ç.w r rnf-þ 206. 4er - e ì qì
V.l.-^i \P''oJ^^-
Environmentol Heolth Division
3020 Rucker Avenue, Suite '104 r Everelt, WA 98201-3900 r fox:425'339'5254' tel:425'339'5250
Porter
Ale
\Nhite
Red
KOSE
ir
t
Lime
Pumpkin Spice Cream
Candied Gi
Fresh Apple
lemon cream
o
6
6
Click Distriþuter
Columbia Distributer
Columbia
Noble*Whes t1 L"
serve w¡th fresh lime juice
mru.gif::/
SNOHOMISH
HEALTH DISTRICT Equipment List
WWW.SNOHD,ORG
Facility name:
List alr food service equipment, incruding make and moder numbers. Exampres include, but are not limited to,
refrigerators, sinks, stoves, ovens, steam tables, blenders, ice machines, ventilation hoods' and all countertop
appliances, lf make and model number cannot be found, a picture of the equipment is required' The item
numbers on this list must be the same as the item numbers for the equipment on the floor plan'
å5iî:trå'*J3"::î:ilîiîî'"î:ï:ä:üËÑËw$åÏ-:i:Ëî;:lîii:ffiiili'iJ'äi:åxi;
one item Per line. ,:).\B'
Sampte Equipment List 'J \-l
l\\\\, 0 tì ?-tlt
tD # Kind of equipment -?:ii"$$ctMake
Model#
1 Refrigerator 8'x8'walk-in ACME R-789W1
2
3
4
lce machine
Rice cooker
3-compartment dish wash sink (with 2 drainboards)
on floor
tM-987
cR-543
S-3CWD
l2-z ru
lo ¿
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q5å-t{6 Iu¿ xrf î
GAPP
ACME
ACME
\ fne equipment list is included
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Environmentql Heqllh Division
3020 Rucker Avenue, Suite ì 04 r Everett, WA 98201-3900 r fox: 425'339 '5254 r tel: 425'339'5250
Please add a second 'H if needed
t ^ic Y2"boo S* tr l¿'? I L
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JUN O ?Û1
F{ealth
Environmenlol Heqllh Division
3020 Rucker Avenue, Suite 104 ¡ Everett, WA 98201-3900 I fox: 425.339.5254 r tel: 425'339.5250
SNOHOMISH
HEALTH DISTRICT Food Preparation SfePs
WWW.SNOHD.ORG
Provide the food preparation steps for all menu items. lnclude how each menu item is obtained, stored,
prepared,cooked, cooled and kePt hot before serving. Menu items in an identicalway may be
grouped tog ether, Menu, food preparation steps,be restricted to Protect Public
health (WAC 426-215).,Ð
JUN o 6 z0itlExamples:
BBe beef/pork - beef and pork are delivered frozen ana srÌncb!!1iñÞ.-walk-in refrigerator to thaw. After the
beef-and pörk are thaweà, they are marinated in our speciåsgHhC¿rlñtthb walk-in refrigerator overnight. Meats
are then óooked on the smoker. After smoking, the beef and pork are shredded and mixed with our BBQ sauce
ànd cooled in hotel pans at 2" food depth in tñe walk-in refrigerator. After meats are cooled to 41'F, they are
covered with plastiiwràp. Meats are reheated in the steamer as needed and kept in the front area steam table
until served. ùefiover items are cooled uncovered in the walk-in refrigerator at 2" food depth.
All hamburgers - patties are purchased frozen. Frozen patties are placed on grillonce ordered. Hamburger
patties are not cooked in advance.
pho soup - beef bones are delivered and stored in the walk-in refrigerator. The beef bones are placed into a
iarge pot, and water is added. The bones and water are brought to ã ooil and vegetables and spices are added.
Áitäi åorp is cooked half of the broth is held hot on the range at above 135'F and the remainder is cooled to
41"F uncovered in the walk-in refrigerator at 2"food depth. The remaining pho soup is reheated to over 165"F
the next daY before use.
chicken salad - raw chicken is purchased frozenand thawed in the walk-in refrigerator. Chicken is marinated
overnigtìt in the walk-in refrigerator. Chicken is cooked on char-broiler, cut into small pieces and placed on
sheet þan at 2" food depth tó cool in the walk-in refrigerator. After chicken has cooled to 41"F, the chicken is
portioned and wrapped. portioned chicken is kept in'the preparation refrigerator until.ordered' Chicken is mixed
ùig, gr""n, ano sålä¿ topping" per order. All saiad greeñs are rinsed each morning ín the food preparation sink
and stored in the preparation refrigerator.
Ham/turkey/roast beef sandwiches - ham, turkey and roast beef are purchased pre-cooked' Meat is sliced
Uálty, po*loned, and jUceC in the preparation refrigerator. All fruits and vegetables are rinsed each morning in
the food preparation s¡nk and stored in the preparaìion refrigerator. Sandw'rches are made to order and served
cold or heated on Panini grill.
shrimp pasta - shrimp is purchased pre-cooked and frozen. Shrimp is thawed in the walk-in refrigerator. Pasta
is par-cooked on stove and cooled at 2" food depth uncovered in the walk-in-refrigerator' once cooled to 41'F,
thà shrimp and pasta are portioned, bagged and stored in the preparation refrigerator' When ordered by
customer, portioned pasta and shrimp are sautéed on stove-top'
Environmentql Heotth Divlsion
3020 Rucker Avenue, Suite .l04 r Everetf , WA 9820ì -3900 r fox: 425'33? '5254 r tel: 425'339'5250
Ã,,ãro€>'
SNOHOMISH
HEALTH DISTRICÏ
WWW.SNOHD.ORG Waste Disposal
Facility name:
Garbage
Name of the comPanY:
Size and type of container
Frequency of pick-uP:
Location of container:
Distance from building:
Waste oil
Name of the comPanY:
Size and type of container:
Frequency of pick-uP:
Location of container:
Distance from building:
Recycling
Name of the comPanY:
Size and type of container:
Frequency of pick-uP:
Location of container:
Distance from building:
,!{ealth
Envlronmentol Heollh Division
3020 Rucker Avenue, Suite 104 ¡ Everetl, WA 98201-3900 r lox 425.339 '5254 t tel: 425'339'5250
sauce - chicken stock, butter, flour, tomato paste, spices - cool in 2" pan in walk in
Precook diced chicken, Uli's sausage, dice peppers' onion' celery
For service - heat sauce in pot, hold in bain marie over 140 degrees
To order: saute ingredients, add sauce and shrimp, simmer
NW gumbo
Sauce: chicken stock, butter, flour, tom' Paste, spices - cool in 2" pan
Precook diced chicken, uli's sausage, onions, celery, oysters
For service - heat sauce in pot, hold in bain marie over 140 degrees
To order: saute ingredients, add sauce and shrimp, simmer
Tomato souP
Simmer garlic, onion, tomato, beer
Puree, heat, hold in bain marie
Serve with shaved smoked mozzarella
0 6 ?t\18
n?åi,T'$$"*
Menu ltems:
Gumbo
Bread
Arepas
Aoli
Mix flour, water, yeast, salt - ferment, shape, proof, bake
Mix masarepa, water, shape, griddle, cool
Bake for service
cook garlic in oil in slow oven with olive oil, puree with mustard, cool
Tomato jam
Chop tomatoes, simmer with spices and honey
Jerk chicken sandwich
Toast, grind sPices
Simmer ginger in simPle sYruP
cabbage , carrot slaw with rice vinegar dressing
For service: season chix, pan roast to 165, glaze with ginger syrup
Blackened tofu sandwich
Season tofu, sear, toP with slaw
Braised pork sandwich
Braise pork with white pepper and saison beer cool 2" pan in walk in
For service: saute veg, add pork, cook 165
Lomo sandwich
Roast pork shoulder, 1.5" cube, cool 2" pan in walk in
Braise onions, cool
Simmer lentils, cool
Pan roast to 165 for seruice, top with quesCI blanco
Blackened salmon sandwich
Wash lettuce
Sear salmon, add corn, Pan roast
Top with butter lettuce, pan fried câpers
Cajun rockfish sandwich
Sear fish with spring onions, smear aoli
Rich boy sandwich
sweat shrimp in butter, top with spring onion slaw, aoli, butter lettuce
Sardine sandwich
Wash romaine, herbs
Sear romaine, top with sardine, aoli, herb gremolata
Ò
Cheese
Melt cheese in oven
Key lime tembleque
Wash, juice, zest limes
Simmer coconut milk, thicken with corn starch, portion' cool
Traditional tembleque
Simmer coconut milk with vanilla, thicken, top with cinnamon
Egg sandwich
Fry egg, top with cheese and sliced chorizo
Pan de Bono
tt
Flour, tapioca starch, cheese, baking powder, milk- bake
SlORAGE
STORAGE
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KTTCHEN / BAR - 302 SF (2 occ)
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ctTY OF EDMONDS . PO BOX 2008 . EDMONDS, WA 98020-2A08'425-771-0241
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Amount Ënclosed
1167750A268.27
948,t 33,140
REVELATIONS YOGURÏ
527 MAIN ST
EDMONDS WA 98020-314e
rl,rr¡lll,rll¡ll¡trlllllhlllhr'tllltl¡,llll¡¡lhlrltlhrl'l¡r¡r
Pleasa detach and ratum loq Porlion wlth Émltlance
Bllllng Dale Due Dáte Amount Due
1-16775 o811112016 09/05/2016 $268,27
Acr¡unt Numbel Bílllno Date Due Date Amount Oue
1-16775 08t11t2016 09/05/2018 $268.27
YOGURT
525 MAÍN Sr
Customer Name:
Service Address
Amıunt
06/13/16
)7'1ts
ail11116
Prevlous Balance
Payment -thank Yqu
Billing
08/1
08/1
1116
1t16
- 08t11t16
- 08/r 1/16
- 08/11116
- 08t11116
ÐÉGEIVÉ
'*-,u* o ß 2il1*
Water
Water Utlt¡tY Tax
Sewor
Sewer Utility Tax
Drain
Utility Tax *?lRl'S"'l*
$91.4e
$17.11
s88,88
t8.8S
t56.27
$5.63
Amount Due:
t251.75
t251.75
'.268.27
$268.27
60
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60
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Metêr#
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Prev Rcad 1
520
Pr€v Read ?
0
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Cun Date
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curr Read t
539
Cun Read 2
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Cur¡ Read 3
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TOTAL
1g
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Water Usage
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