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Please provide all information requested; an incomplete application may delay approval <br />❑ FACILITY INFORMATION <br />Name of Facility: ' hid BAC <br />Street Address: 44 S W , WONe R-- I <br />City: Zip Code: q <br />❑ FORMER NAME OF FACILITY <br />[]BUSINESS OWNER INFORMATION r <br />Business Owner Name: L04,aikot. <br />Home Address: 8q&A <br />Mailing Address: QS G✓h2 YtSS <br />Telephone Number: ( SS — �-I <br />❑ PROPERTY. OWNER INFORMATION <br />Property Owner Name: Cktlt t'urlt t�kkrp-hoU,Q CLC <br />Home Address: <br />Mailing Address: <br />Telephone Number: <br />❑ CONTRACTOR INFORMATION <br />Name of General Contractor: <br />Mailing Address: <br />Telephone Number: <br />Contact Person on Site: <br />Site Phone Number: <br />❑ UTILITIES <br />Source of Facility Water Supply: <br />Backflow Protection: <br />System to be used for Liquid Waste Disposal (Sewage): <br />Solid Waste Disposal to be provided: <br />Grease Interceptor: <br />❑ FOOD INFORMATION <br />List food(s) to be served and/or provide menu: <br />yy�oo}1�ie5 A A ff rvaW Rx.raea . e- <br />d <br />❑ OPERATIONAL INFORMATION <br />Anticipated Business Hours: Open: fg IlX1 qw Close: 5IXI 121", <br />Anticipated Number of Employees: <br />EHD 16-01 4 PLAN CHECK GUIDE <br />7/5/17 <br />