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ealth <br /> al <br /> RAMSEY COUNTY 5 Malewood,MN 55109 White Bear Ave INo tht5u to 350 <br /> C <br /> --Saint Paul Ramsey County Public Health P <br /> 651-266-1199 <br /> iamseycuunty.us <br /> COMMUNITY ENVIRONMENTAL HEALTH LICENSE APPLICATION <br /> SEND THIS COMPLETED APPLICATION TO:RatllseVCEH@co.ranlseV.11111.u5 or mail to the address listed above. <br /> A FEE STATEMENT FOR THIS LICENSE WILL BE EMAILED TO THE BILLING CONTACT IDENTIFIED BELOW WITH PAYMENT INSTRUCTIONS AFTER <br /> REVIEW BY RAMSEY COUNTY ENVIRONMENTAL HEALTH STAFF. <br /> ESTABLISHMENT SITE INFORMATION <br /> Establishment Name(Doing-Business-As/Assumed Name): <br /> Establishment Address: V City <br /> �\ State: Zip Code: <br /> I J 5 I`. �:VI14' 0\�v.: \� �'�V��/It Jae V�; MN ��`�112 <br /> Email Address: Phone: <br /> ro501C CA_S t c1�� c�`t 1�o�+ 1 i 1 <br /> Planned date of opening(or date of official ownership change if an existing establishment): <br /> D tes of operation: <br /> Year-round 0 Seasonal,list months of operation: <br /> CORRESPONDENCE <br /> Establishment Site Contact <br /> Site Contact Person Name: Title: Phon Email: <br /> �c�r�t` tv CL1,vtncl f��c:;lnc. �,r �'l�L�z i� 2� ��`><<c�As���v,-c �I� �`�C`jw^HI I ����• <br /> Legal Entity/Licensee Contact <br /> Legal Entity Name(write own is name if Sole Proprietorship): Type of Legal Entity(such as sole proprietor,LLC,LP,INC,etc.): <br /> Licensee Care-of Person Name: Titl Phony/ Email: <br /> >� Cvi�Ov�CI vlf b �l'j1 I� � ?S1 � <br /> M 'ling Address: City: State: Zip Code: <br /> Billing Contact �c,`w\c Glll�_) c;`�joQe <br /> Legal Entity Name(write"N/A"if Same as Legal Owner Above): Type of Legal Entity(write"N/A"if Same as Legal Owner Above): <br /> Billing Care-of Person Name: Title: Phone: Email: <br /> Billing Address: City: State: Zip Code: <br /> Emergency Contact <br /> Emergency Contact Person Name: Title: Phone: Email: <br /> h'lC{v�CC'10 Cc�Y��'�'-)c� I(Y1t,�b1� �r� ( 111,2(7-Z� 2`r ��.��trc���<tL1�� � �����-r.,a'i,Ccz�► <br /> 8.29.2023 <br />