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I AFFItlF IISF fNLY t h•- DEPARTMENT OF AGRICULTURE 141100 Source Code '�'Y ' DAIRY&FOOD INSPECTION DIVISION . •�,, Fee Received ri 90 WEST PLATO BOULEVARD Plans received t' ST. PAUL, MN 55107-2094 Date RETAIL FOOD STORE SANITATION PLAN REVIEW APPLICATION The hennaed*Rene Food Stere Sanitation Rules(Minn.Saki 1547.0110,Subp.2),as emended,requires the reel food store to pay a plan review fee to the Deperam.nt of Agriculture alone with the required plans and eat or m complete riandod : ing n the ti s app pficabon drhmalong with the plans,spsdAaitlre oand appropriate remittance to the Minnesota DepaimMM a Agriculture for review and approval prior to start of sonsbisollon,The date whldh you supply on this tem will be used to prowls your appt8stm. You are not legally required to provide this data,but we we not be able to grunt the Scenes without it. The appYalgon was adutltltb a pubid retard If area when the ticawe is granted,except for your Soda Security Number,business Federal Tax identllation Number,and Minnesota Ilueaieee(Tax)idarrUntlon Number, Anypia may request copies or application at the time the license is granted. However,we will withhold the enumerated data. Business Name Check(J)the appropriate box below: Owner's or Corporate Nam New Construction 0 Social Security No.or Federal Tax I.D.No. *Major Remodeling 0 tEl Minnesota Business LD.Number Conversion Store Address(Street Address) Please attach your plans and specifications to this application. City.State,2ip Code&County Basic description of the type of operation(s): Telephone Number(Business) 7 .. Mailing Address(it different from store address) —. -- , 7i 2-2Ex.," - ..4---41,0‘..)- .,(2--,E.;-.1-..; 1 Minnesota Statutes Sections 176.182 and 270.72 requires you to provide the Department tf the answer to this question is"YES."please tat name es,city,state and zip Wet (1)acceptable evidence of compliance with the workers compensation lneuance law code of your workers'conversation carrier. and(2)your Federal Tax I.D.number,Social Security number or Minnesota Business ID. number. If you are self-tested,please attach a copy of the exemption order from the Commissioner of Commerce authorizing self-insurance. WE CANNOT ISSUE THIS PERMIT WITHOUT THIS INFORMATION. Policy Number Do you have any paid or otherwise compensated employees? YES NO Effective Dates to The plan review fee structure is based on the square footage of the structure being constructed, remodeled or converted as prescribed below: 'Major Remodeling-calculate ,� square footage only of the area List the actual square footage of new, remodeled or converted structure / tis' being remodeled. REQUIRED PLANS AND SPECIFICATIONS: Square Footage(ft2) Review Fee(Mark Appropriate Box) FLOOR PLANS-Equipment location and planning; Less than 5,000 $125.00 F.4 TOTAL FEE REMITTED ROOM FINISH SCHEDULE•Walls,floors,calling; 5,000-24,999 $115.00 0 EQUIPMENT USTING-Manufacturing and modal numbers. 25,000 or Greater $275.00 0 Return this form,the plans and speaific i- tions with yout remittance payable to: ConstructionpgAnticipated Start Minnesota Department of Agriculture (Date) Financial Administration Division Anticipated Completion 90 West Plato Boulevard (Date) St. Paul,MN 55107-2094 Applicant's Name(please print) Please direct all inquiries to the Dairy&Food Inspection Applicant's Signature Division,Plan Review Officer,at 651/296-2627. Title Date in accordance with the Americans With Disabilities Act,an alternative form of communication is available upon request TTY: 1-800-827-3529 AG010114.03(03199)