Southern Nevada Food Plan Review

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Southern Nevada Food Plan Review Powered By Docstoc
					                                 330 S. Valley View Blvd., Las Vegas, NV 89107
                                         (702) 759-1258 | www.snhd.info

                               PLAN REVIEW APPLICATION
                           OWNERSHIP INFORMATION (PERMIT HOLDER)
OWNER OF BUSINESS: (CORPORATION, PARTNERSHIP, LLC, OR SOLE PROPRIETOR)


OWNER ADDRESS: (STREET, CITY, STATE, ZIP CODE)


OWNER CONTACT INFORMATION: (PHONE NUMBER AND EMAIL ADDRESS)




                                    BUSINESS INFORMATION (DBA)
BUSINESS NAME: (DBA)


BUSINESS ADDRESS: (STREET, CITY, STATE, ZIP CODE)


BUSINESS CONTACT INFORMATION: (PHONE NUMBER AND EMAIL ADDRESS)




   OWNER’S SIGNATURE:____________________________________ DATE:________________________________

    PLEASE PRINT OWNER’S NAME:_________________________________________________________________

              PLEASE CALL TO MAKE AN APPOINMENT TO SUBMIT PLANS FOR REVIEW. 702.759.1259

         PLAN REVIEW AND ANNUAL HEALTH PERMIT FEES MUST BE PAID AT THE TIME OF APPOINTMENT.
      PLAN REVIEW AND HEALTH PERMIT FEES ARE NOT REFUNDABLE. NO EXCEPTIONS.
                          FEES ARE DETERMINED AFTER YOUR PLAN REVIEW MEETING.

             FORMS OF PAYMENT: CASH, VISA, MASTERCARD, BUSINESS CHECK, OR MONEY ORDERS

                                    FEE SCHEDULE CAN BE LOCATED AT:
                http://www.southernnevadahealthdistrict.org/download/eh/eh-fee-schedule.pdf
OFFICE USE ONLY:
          AFTER THE FACT [ ]    REVISED PLANS [ ]       PRELIMINARY PLANS [ ]    BUILDING MEMO [ ]
NOTES:




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                                                        ALL PERMIT TYPES
PROJECTED DATE OF OPENING: ____/____/____     HOURS OF OPERATION: OPEN________ _ CLOSE_________
SEPTIC TANK: (CHECK ONE)                      WATER SUPPLY: (CHECK ONE)
YES [ ] NO [ ] NA [ ]                         WELL [ ] MUNI SYSTEM [ ] NA [ ]
# OF EMPLOYEES: _____      # OF RESTROOMS: _____ NA [ ]       # OF DRIVE THRU WINDOWS _____ NA [ ]
                 FOOD ESTABLISHMENT PERMITS (CHECK ONE: [ ] NEW [ ] REMODEL)
CHECK ALL THAT APPLY:
[ ] RESTAURANT # OF SEATS ______               [ ] BAR/SERVICE BAR # OF SEATS _____ ( [ ] RESTRICTED [ ] UNRESTRICTED)

[ ] SNACK BAR # OF SEATS ______ [ ] KITCHEN SQ FT ______ [ ] MARKET SQ FT ______ [ ] BAKERY SQ FT ______

[ ] FOOD PROCESSOR SQ FT ______                    [ ] WAREHOUSE SQ FT ______                     [ ] OTHER SQ FT ______
NCIAA (NEVADA CLEAN INDOOR AIR ACT) AFFIDAVIT: I, THE APPLICANT OR DULLY AUTHORIZED AGENT OF THE APPLICANT, DO HEREBY ATTEST AND AFFIRM THAT
        THE AFOREMENTIONED FACILITY IS [ ] EXEMPT OR [ ] NOT EXEMPT FROM COMPLIANCE WITH THE REQUIRMENTS OF NRS 202.2483 INCLUSIVE.
                                              CHILD CARE/SCHOOL PERMITS
[ ] CHILD CARE FACILITY SQ FT ______/# OF CHILDREN ______                    [ ] SCHOOL ( [ ] ELEM [ ] JRHS [ ] HS )
                                                 MOBILE VENDING PERMITS
[ ] MOBILE ICE CREAM/CANDY [ ] MOBILE FOOD UNIT (PREPACK FOOD) [ ] MOBILE FOOD SERVICE (OPEN FOOD)
VEHICLE INFORMATION: (MAKE, MODEL, & YEAR)   VIN #:                     LICENSE PLATE #:

COMMISSARY INFORMATION: (NAME, FULL ADDRESS, AND PHONE NUMBER)

     PLEASE PROVIDE A COPY OF THE DMV REGISTRATION AND A COPY OF THE AGREEMENT WITH COMMISSARY
                                         FARMERS’ MARKET VENDOR PERMITS
[ ] SAMPLING      [ ] PROCESSED PRODUCE      [ ] LOW RISK    [ ] HIGH RISK    [ ] NATURAL STATE
FARMERS’ MARKET INFORATION: (NAME, FULL ADDRESS, MARKET MANAGER, AND PHONE NUMBER)

EVENT TO BE HELD: [ ] ENCLOSED BUILDING [ ] OUTDOOR [ ] BOTH
DAY(S) OF MARKET: [ ] SUN [ ] MON [ ] TUE [ ] WED [ ] THU [ ] FRI [ ] SAT SET-UP TIME: ______
COMMISSARY INFORMATION (IF APPLICABLE): (NAME, FULL ADDRESS, AND PHONE NUMBER)

PLEASE PROVIDE A COPY FROM FARMERS’ MARKET MANAGER AND A COPY OF THE AGREEMENT WITH COMMISSARY
               ANNUAL ITINERANT PERMITS (CHECK ONE: [ ] LOW RISK [ ] HIGH RISK)
FIRST EVENT INFORMATION: (NAME, FULL ADDRESS, EVENT COORDINATOR, AND PHONE NUMBER)

COMMISSARY INFORMATION: (NAME, FULL ADDRESS, AND PHONE NUMBER)

                              PLEASE PROVIDE A COPY OF THE AGREEMENT WITH COMMISSARY
                                                SEASONAL HEALTH PERMITS
LOCATION #1: (FULL ADDRESS)
                                                                     # OF MONTHS ___            FROM ___________ TO __________
LOCATION #2: (FULL ADDRESS)
                                                                     # OF MONTHS ___            FROM ___________ TO __________
LOCATION #3: (FULL ADDRESS)
                                                # OF MONTHS ___  FROM ___________ TO __________
      PLEASE PROVIDE LEASE AGREEMENT WITH PROPERTY OWNER INCLUDING RESTROOM ACCESSIBILITY
COMMISSARY INFORMATION: (NAME, FULL ADDRESS, AND PHONE NUMBER)

                              PLEASE PROVIDE A COPY OF THE AGREEMENT WITH COMMISSARY



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