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~~ Marion Count~ <br />Health & Se.~ices Bui g <br />~ 3180 Ccsi ccr S a-cet NE ~-- <br />Salem, OR 97301-4592 <br />IS THIS A NEW RESTAURANT FACILITYAND~~OC lTA O~N ' <br />ARE YOU RENEWING A LIC~iVSE HELD 8Y YOU? <br />WAS THIS ESTABLISHMEi~lT LIC~~ISED PREVIOUSLY? <br />_. ~ . ~ . ...... ~-~.'c~ y <br />IN WHIC}i UC~NSE ISSUANC~ 1S L <br />County Iicense fee $ <br />Plus Slate surcharge fee $~- <br />EQUA~S $ ~_ TOTA~ OUE <br />TELEPHONE <br />S03 -351-7~~-G <br />~ ~:.~.~U ~~ S L~.,~,~-~~= ~ r~ clb ~ ~ t~' ~ ~~ ; ti~ 1-~-~ <br />NAME OF IEGAL OWNER{S) -{NAMES OF INOIVIDUALS IN PAATNERS7ilp CR CARPOFiA7}pNJ ~~ <br />~ ~L~%~L~ ~ ~'i ~ <br />_ ~ . ~c s ~^,~G~~ ~ _ T ~-' C.~ <br />M.v.nucn ~v~+m~ - i~ v ~ ttttl i hwn ltCiAL CJWNER TELEt~HONE <br />...5~~-~~ ~!~,~.~, -~ ~c 3 - ~~ s---7 a.~e, <br />BUS~NESS MAIUNGADOAESS STREE'f CiTY S7ATE Z~p <br />~- ~. c3 c x ~~i / 3 C'~= ~~ ~~;~-c.c_~ s LT ,~ ~:,~ 3~ <br />BUStNESS LOCdTION - IF OTHER THAN ABOVE STREET CtTY STATE Z~p <br />.-1~~r L~.-~--'~z~"~ ~ j~;G~rY) Cy <br />/ <br />PLEASE CHECK AND COMPl.ETE THE FO~LOW(NG <br />Tt5 NU <br />Q~ ~ <br />~ <br />a' a <br />`~~ <br />NAtvIE OF~FORMER ~ICENScc <br />, <br />-- ~~ cL~~.~,'G- J <br />APPL1CATlON FOR <br />RESTAURANT L1CEN~ <br />ENVIRONMENTAL H~ALTH ~ <br />588-5346 <br />DATE OF OPENING <br />s/~/~~ <br />U A I E OF t_AS 7 OP E r'iATiCN <br />~~ ,~~ i ^-~- <br />t5 iAtiUSHMENT FORMER NAME <br />!~,^ L, u . , -• ~~ .+~-~-!-, ~ ~. <br />-~ ~ <br />TOTAL NUMBER OF SEATS ~~ - 5~- (EACt-124' OF BOOTH SPACE = t SEAI~ <br />P~ease note: Licenses are not transferrable and expir~ <br />December 3I or upon change of ownership. <br />MAKE ALL CHECKS PAYABLE, AND MAIL TO: <br />Marion County Env Health <br />3180 Center St. NE, Rm ~25~ <br />Salem, OR 97301-4592 <br />A{~plication is hefeby made to operate the above esiablishment in compiiar~ with ~he p~ovisions of Oregon Revised <br />Siatutes, Ct~apter 624, and the Adminisirative Rules of the Oregon State Heatth Division pursua~ thereto. Paymern of <br />the ~equired fee is hereby made with the undersianding that faiiure to meet the ~equirements of ihe Oreyon Revised <br />Slatutes, Cnapter 62a, and the Adminisirative Ruies oi Oregon Siate Heafth ~ivision require deniai o~ ticerise revocation. <br />APPLICANT SiGyATURE ~. HOME 8~ BUSINESS PHONE <br />~U~~ ~CI ^,.~ l!' ~~~ ,;=~y ~ . ~f-~.i~' ~~' ~! -- ~C~l- <br />% / ~- ~ - <br />HOME ApDRESS C~ ~~~ C1TY ~ STATE ZIP <br />~ d <br />~-~ ~^~~__J~~~ %~ ,-~~, ~C;'_~; ~._, ~`-,L yr~~ ~ <br />~ ~' l ~. <br />FEE OF 5 <br />INSPECTION MAOE BY: <br />APQROvED: <br />RECEiVED <br />~'L c. ~i. ~c-, <br />DO NOT WRIT~ IN TFiIS SPAC~ <br />DATE: <br />0 AT E: <br />UNAPPROVED: <br />