Laserfiche WebLink
FOR BO/MD OF 1-11Z 1'1-1 USE ONLY <br /> Date Received Date lnspec(ed Approved By Permit tt ISSUCd <br /> c/-o1C9 �3 0 �lto 3 <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> TOWN OR CITY OF MIAI� nee SEP 26 2013 <br /> Food Establishment Permit Applicatio113®ARDOFHEALTH <br /> (Applicotin)7mast be submitted of least 30 days before the plonned openi)vg dote) <br /> I. Establish men(.Name: L rPt 146mr . tjt LLC- <br /> 2. Establishment Address: 996 Nf1 vAm <br /> 3. Establishment Mailing Address(if different): <br /> d. Establishment Telephone No: '7$ <br /> 6. Applicant Name & Tide: Lvi-U rn Co tili v. <br /> 6. Applicant Address: Email Address Lt4U r A I' 6L C6ct� <br /> 7. ApplicAritTelephone:No: 7$1-7LoG 24Hour EmergencyNo:je <br /> 8. Owner Name&Tide (if differenr from applicant): <br /> 9. Owner Address (if.different from applicant): _ <br /> 10. Establishment Owned By: 11. If a Corporation or Partnership, give name, tide, and home address of <br /> 13 An Associationofficers or panner. <br /> - Name - 'de Home Address <br /> ❑ AA Corporation i <br /> FV— An.Individual <br /> ❑ A Parmership . <br /> ❑ Other Leaal Entity - - <br /> 12. Person Directly Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager, etc.) <br /> Name &Title: -- --- — <br /> Address: ' In1 — mr-,5V v-e-P <br /> Telephone No: <br /> Emer_ency Telephone No: Far: <br /> 13. District or Regional Supervisor(if applicoble) <br /> Name R Title: <br /> Address: <br /> Telephone No: Fax: <br />