Backup Documents 12/11-12/2012 Item #16D31 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
THE BOARD ACCMPANY ALL ORIGINAL DOCUMENTS SENT n
OF COUNTY COMMISS ONERS OFFICE FOR SIGr
Print on pink paper.Attach to original document.Original documents should be hand delivered to the Board Office.The completed routing slip and original
documents are to be forwarded to the Board Office only after the Board has taken action on the item.)
ROUTING SLIP
Complete routing lines#1 through#4 as appropriate for additional signatures,dates,and/or information needed.If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#4,complete the checklist,and forward to Sue Filson(line#5).
Route to Addressee(s) Office Initials Date
(List in routing order)
1. Colleen Greene County Attorney's Office
2. Board of County Commissioners Board of County Commissioners
3. Minutes and Records Clerk of Courts r2j
4.
5.
6.
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending BCC approval.Normally the primary contact is the perspn who created/prepared the executive
summary.Primary contact information is needed in the event one of the addressees above,including Executive Manager,need to contact staff for additional or
missing information.All original documents needing the BCC Chairman's signature are to be delivered to the BCC office oily after the BCC has acted to approve
the item.)
Name of Primary Staff Natali Betancur Phone Number ,239-252-4059
Contact
Agenda Date Item was December 11,2012✓ Agenda Item Number 16D31
Approved by the BCC
Type of Document Food Permit Application Number of Original .4 Sex -
Attached Documents Attached c�. txet� �cSl\S
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Original document has been signed/initialed for legal sufficiency.(All documents to be Yes
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions,etc.signed by the County Attorney's Office and signature pages from
contracts,agreements,etc.that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and possibly State Officials.)
2. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
3. The Chairman's signature line date has been entered as the date of BCC approval of the Yes
document or the final negotiated contract date whichever is applicable.
4. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's Yes
signature and initials are required.
5. In most cases(some contracts are an exception),the original document and this routing slip N/A
should be provided to the Executive Manager in the BCC office within 24 hours of BCC
approval. Some documents are time sensitive and require forwarding to Tallahassee within
a certain time frame or the BCC's actions are nullified.Be aware of your deadlines!
6. The document was approved by the BCC orr6ctobet-9 and all changes made Yes
during the meeting have been incorporated in the attache ocume t.The County
Attorney's Office has reviewed the changes,if applicable. \Z\\\\\Z
■
IVE, , .,„...„: Florida Department of Agriculture and Consumer Serlices16 0 3 1
~ Division of Food Safety
Remit Food Permit fee online at:
'-'� FOOD PERMIT APPLICATION www.FreshFromFlorida.pay -OR- Send
Check or
''. ¢loney Order payable to FDACS
`�'4 in enclostd envelope to:
ADAM H. PUTNAM Chapter 500, Florida Statutes FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
COMMISSIONER (850) 245-5520 PO BOX 6720
TALLAHASSEE, FL 32314-6720
2013 FOOD PERMIT NOTICE October 25, 2012
IIIulIIIIIIIlIIIllIIIIIIIIIIIII,IIIIIII IIIIIIIIIIIIII.IIIIIIIIIII q Ec E l V E rl
COLLIER COUNTY PARKS ` ti OCT 3 0 2012 J
15000 LIVINGSTON RD
NAPLES, FL 34109-3808 Parks and Recreation
S0/67 /i161/0 3
Permit Year Type: Permit Fee Epidemiology Late Fee Amount Paid Balance Due
Fee
2013 R $130.00 $10.00 $140.00
I TOTAL NOW DUE: I $140.00
BUSINESS INFORMATION for Firm No. 296315 OWNER INFORMATION
COLLIER COUNTY CAXAMBAS PARK MARINA COLLIER COUNTY PARKS -7p �J
909 COLLIER CT 15000 LIVINGSTON RD -
MARCO ISLAND, FL 34145-6514 NAPLES, FL 34109-3808 rn Z 11
Sanitation Rating: GOOD as of 08/02/2012 FEIN: a) •
Firm Status: ACTIVE Business Type: BUSINESS 0
Firm Type: MINOR OUTLET LIMITED SALES Q W
Phone: (239)642 0004 o im
n r- ~,
The Department will issue a Food Permit after receipt of the required fees and the completed application (rever sid Z
and will mail the permit to your business address. Return your completed application and payment by Decemb — 20 2. MI
This will insure issuance of our ermit b December 31 2012. All 2012 Food Permits ex•ire on December 31 2012. -_
FDACS-14326 Rev.09/12
Carefully tear along the perforation,and mail the signed coupon (bottom portion)and your payment in the envelope provided OR
remit payment online with coupon at www.FreshFromFlorida.com.
(Please use the reverse side of this coupon to provide any additional Business or Owner information,
or to make any changes to the information shown above.
``ti` The signature of an authorized individual must be provided on the reverse side of this coupon.)
0 obey 25, 2012'
2013 FOOD PERMIT NOTICE FOR FIRM NO. 296315 EC E
COLLIER COUNTY CAXAMBAS PARK MARINA ED
(TOTAL PERMIT FEES NOW DUE: S140.00 NOV 2 � 2012
1
FINANCE
llllll'I I1II II hhhJ9II 1IIII1II11IIII'IIIIIIalllIIIIllllluIll lllll
FLORIDA DEPARTMENT OF AGRICULTURE ND
CONSUMER SERVICES
PO BOX 6720
FDACS-14326 Rev. 09/12 TALLAHASSEE, FL 32314-6720
0002 4 0000302248 1 0000000000 0 0001421983 4 0000014000 7
The Department of Agriculture and Consumer Services, under authority of Chaper 500, Florida Statut
kth xc�si
regulatory and permitting authority for any person, business or corporation engaged in manufacturing sj,D�tclUg,
holding or preparing food or selling food at wholesale or retail. Operating a Food Establishment without a current Food Permit
is a violation of Chaper 500, Florida Statutes, and is punishable by a fine of up to $5,000. For purposes of this application,
"food" is considered to include, but is not limited to, all prepackaged foods, prepared foods, packaged ice, bottled water, candy
and other snack foods, soda, infant formula, and vitamin or mineral dietary supplements.
If the business identified on the reverse side has been transferred to a new owner please call (850)245-5520 for
information on how to obtain a correct Food Permit. Do not return this Payment Coupon or the payment when the
business has been transferred to a new owner.
The business identified on the reverse side must obtain or renew its Food Permit, as follows:
1. Please review the Business Information and the Owner Information shown on the reverse side, and provide any
corrected or missing information in the spaces below, and
2. Separate and return the Payment Coupon payment for the amount shown as TOTAL NOW DUE, using the return
envelope provided OR remit payment online with coupon at www.FreshFromFlorida.com.
3. If you manufacture and/or package ice for sale, or if you bottle water for sale, you must also submit in writing with the
Payment Coupon:
a. Source(s) of water used.
b. Any treatment provided to ice prior to packaging.
After the Department receives the payment coupon and payment, your Food Permit will be mailed to the address shown under
Owner Information on the reverse side of this application.
However,
If your most recent inspection by the Department's Division of Food Safety resulted in a Sanitation Rating of "Poor",
or if your firm has any outstanding balances due (such as: unpaid permits, unpaid administrative fines, unpaid re-
inspection fees, or outstanding returned checks*), you are not in compliance with statutory requirements. Your food
permit will not be issued until your sanitation rating and all payments are in compliance.
Payment for your Food Permit is due immediately. All Food Permits expire on December 31. It is your responsibility to renew
your Food Permit each year prior to expiration. Return this completed application and your payment immediately, to assure the
issuance of your Food Permit.
The Department will assess an additional fee of $100 for late payment.
* If the "business information" section of the revere side states a "Firm Status" of "RTD CHECK" this means that a
check previously submitted by you has been dishonored by your bank. All payments will first be applied to cover
the outstanding returned check. You will not be issued a Food Permit until all past due accounts are paid in full.
This application must be signed by the applicant, owner or chief executive of the applicant, without the need for
witnesses. If a corporation is in the hands of a receiver or trustee, this application shall be executed on behalf of the
receiver or trustee. �, 1
nformation ,
., Corrected Business Informs `
Name
Address
City/State/Zip Code
Phone
Owner email: Owner FEIN:
Department use Only
1'
By my signature below, I certify that I am empowered to execute this application as req ;r d,by Chapter 500, Florida Statutes.
iAppr`o`d as to`form&legal sufficiency , / Fred y� O .. . 111..F-.!; ' •' f k3,f,, \7_2
A. • g i ► �, Printed Name / - •
DWIGHTE.8"• diERK Date
Co* Greene, PA' , fit IS to Os i '
Accictant County Attorney — --�-�-T�-�:.
{ 1 Florida Department of Agriculture and Consumer Se ices 1 6 D 3 �+L
iDivision of Food Safety
°� Remit Food Permit fee online at:
'�, FOOD PERMIT APPLICATION www.FreshFromFlorida.pay -0R- Send
•
r Check or Money Order payable to FDACS
�ti in enclosed envelope to
Chapter 500, Florida Statutes FLORIDA DEPARTMENT OF AGRICULTURE AND
ADAM H.PUTNAM CONSUMER SERVICES
COMMISSIONER (850) 245-5520 PO BOX 6720
TALLAHASS)#E, FL 32314-6720
2013 FOOD PERMIT NOTICE October 25, 2012
I1II11II1III 111111IIIIIIIII 1II IIJI I,IIJIIIII'JIIIJ.l.II1III1II1' )6-EC—En/ ED
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS PARKS
3 0 2012
15000 LIVINGSTON RD
NAPLES, FL 34109- 3808 I Parks and Recreation
/
f Q/!2 807452 A pw243
Permit Year Type: Permit Fee Epidemiology Late Fee Amount Paid Balance Due
Fee
2013 R $190.00 $10.00 $200.00
I TOTAL NOW DUE: $200.00
BUSINESS INFORMATION for Firm No. 342374 OWNER INFORMATION
GOODLAND BOAT PARK COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS PARKS
740 PALM POINT DR. 15000 LIVINGSTON RD
GOODLAND, FL 34140 NAPLES, FL 34109-3808 '
Sanitation Rating: as of FEIN: 59-6000558
Firm Status: ACTIVE Business Type: CORPORATION Z �W
Firm Type: MINOR FOOD OUTLET W/ONLY NON-PERISHABLE FOODS Phone: (239)252-4000 o
� C
C�
The Department will issue a Food Permit after receipt of the required fees and the completed application (reverse tie o
and will mail the permit to your business address. Return your completed application and payment by December �•01
This will insure issuance of your permit by December 31, 2012. All 2012 Food Permits expire on December 31, 2•E 2. ,z,
o
FDACS-14326 Rev. 09/12
LoJ
Carefully tear along the perforation,and mail the signed coupon(bottom portion)and your payment in the envelope provided OR
remit payment online with coupon at www.FreshFromFlorida.com.
(Please use the reverse side of this coupon to provide any additional Business or Owner information,
or to make any changes to the information shown above.
The signature of an authorized individual must be provided on the reverse side of this coupon.)
Oc ober 25, 2012
2013 FOOD PERMIT NOTICE FOR FIRM NO. 342374 RECEIVED
GOODLAND BOAT PARK NOV 2 1 2012
(TOTAL PERMIT FEES NOW DUE: $200.00
FINANCE
I
IIIIIIIIIIIII1IIIIIIIIII.IIIIIIIIII II1.111.IIIII,II1IIIIII1 1,111
FLORIDA DEPARTMENT OF AGRICULTURE ND
CONSUMER SERVICES
•
PO BOX 6720
FDACS-14326 Rev. 09/12 TALLAHASSEE, FL 32314-6720
0002 4 0000351344 4 0000000000 0 0001437350 9 0000020000 8
The Department of Agriculture and Consumer Services, under authority of Chaper 500, Florida Stat e s e us e
n business or corporation engaged in manufacturi . e n a•ng,
regulatory and permitting authority for any person, p
holding or preparing food or selling food at wholesale or retail. Operating a Food Establishment without a current Food Permit
is a violation of Chaper 500, Florida Statutes, and is punishable by a fine of up to $5,000. For purposes of this application,
"food" is considered to include, but is not limited to, all prepackaged foods, prepared foods, packaged ice, bottled water, candy
and other snack foods, soda, infant formula, and vitamin or mineral dietary supplements.
If the business identified on the reverse side has been transferred to a new owner please call(850)245-5520 for
information on how to obtain a correct Food Permit. Do not return this Payment Coupon or the payment when the
business has been transferred to a new owner.
The business identified on the reverse side must obtain or renew its Food Permit, as follows:
1. Please review the Business Information and the Owner Information shown on the reverse side, and provide any
corrected or missing information in the spaces below, and
2. Separate and return the Payment Coupon payment for the amount shown as TOTAL NOW DUE, using the return
envelope provided OR remit payment online with coupon at www.FreshFromFlorida.com.
3. If you manufacture and/or package ice for sale, or if you bottle water for sale, you must also submit in writing with the
Payment Coupon:
a. Source(s) of water used.
b. Any treatment provided to ice prior to packaging.
After the Department receives the payment coupon and payment, your Food Permit will be mailed to the address shown under
Owner Information on the reverse side of this application.
However,
If your most recent inspection by the Department's Division of Food Safety resulted in a Sanitation Rating of "Poor",
or if your firm has any outstanding balances due(such as: unpaid permits, unpaid administrative fines, unpaid re-
inspection fees, or outstanding returned checks*), you are not in compliance with statutory requirements. Your food
permit will not be issued until your sanitation rating and all payments are in compliance.
Payment for your Food Permit is due immediately. All Food Permits expire on December 31. It is your responsibility to renew
your Food Permit each year prior to expiration. Return this completed application and your payment immediately, to assure the
issuance of your Food Permit.
The Department will assess an additional fee of $100 for late payment.
* If the "business information" section of the revere side states a "Firm Status" of "RTD CHECK" this means that a
check previously submitted by you has been dishonored by your bank. All payments will first be applied to cover
the outstanding returned check. You will not be issued a Food Permit until all past due accounts are paid in full.
This application must be signed by the applicant, owner or chief executive of the applicant, without the need for
witnesses. If a corporation is in the hands of a receiver or trustee,this application shall be executed on behalf of the
receiver or trustee.
.� , .> , �
�. , _.:. Corrected Business Information i .; r'. ..:Corrected Own
Name
Address
City/State/Zip Code
Phone
Owner email: Owner FEIN:
Department use Only
By my signature below, I certify that I am empowered to execute this application as req Fred by Chapter 500, Florida Statutes.
c___}Approved as to form&legal-sufficiency ,,,, / / / , / I'"7
-. , - cs
Fxed. w C9y,ligaggipa rrt aR 1.,_k k \ \\ 1Z
Applica ;.-�jt'f'f m..An :dWiY ' Printed Namei DWIGHT E.BROCK,CLERK Dat
Colleen reeve, t �r' '
istant County Attorney N
.... ..
5y Florida Department of Agriculture and Consumer Services 6 IJ 3 1
.s, Division of Food Safety
Remit Food Permit fee online at:
+'�° www.FreshFromFlorida.com -OR- Send
�' FOOD PERMIT APPLICATION Check or None Order
y payable to FDACS
'ti in enclosed envelope to
cciii Cha ter 500, Florida Statutes FLORIDA DEPARTMENT OF AGRICULTURE AND
ADAM H. PUTNAM p CONSUMER SERVICES
COMMISSIONER (850) 245-5520 PO BOX 6720
TALLAHASSEE, FL 32314-6720
2013 FOOD PERMIT NOTICE October 25, 2012
ECEI En�
..1.41IIIIIIIIIIIIIIIIIIIIIIP.VIII"IIIIIIII'IIIII'I'IIIIIII'II' ! ii
COLLIER COUNTY BOARD OF COUNTY COMMISSIONER OCT 3 0 2012 .._i
15000 LIVINGSTON RD Par s and Recreation
NAPLES, FL 34109- 3808
507 c5D /417//W2-83
////4/ 2-,
Permit Year Type: Permit Fee Epidemiology Late Fee Amount Paid Balance Due
Fee
2013 R $130.00 $10.00 I $140.00
I TOTAL NCIA, DUE: I $140.00
BUSINESS INFORMATION for Firm No. 313539 OWNER INFORMATION
COCOHATCHEE RIVER MARINA COLLIER COUNTY BOARD OF COUNTY COMMISSIOFR :=!.&J 1
13535 VANDERBILT DR 15000 LIVINGSTON RD �- Z Fri
NAPLES, FL 34110-6085 NAPLES, FL 34109-3808 cn CD
Sanitation Rating: GOOD as of 01/10/2012 FEIN: 59-6000558 c n
Firm Status: ACTIVE Business Type: CORPORATION a CAD ra
Firm Type: MINOR OUTLET LIMITED SALES Phone: D3 o
op
The Department will issue a Food Permit after receipt of the required fees and the completed application (revete sic A,
and will mail the permit to your business address. Return your completed application and payment by Decembeel, 2012. l°
This will insure issuance of your permit by December 31, 2012. All 2012 Food Permits expire on December 31. 2012.(!.,----0
FDACS-14326 Rev.09/12
Carefully tear along the perforation,and mail the signed coupon(bottom portion)and your payment in the envelope provided OR
remit payment online with coupon at www.FreshFromFlorida.com.
jPlease use the reverse side of this coupon to provide any additional Business or Owner information,
or to make any changes to the information shown above.
The signature of an authorized individual must be provided on the reverse side of this coupon.)
0 ober 25, 2012
2013 FOOD PERMIT NOTICE FOR FIRM NO. 313539 .;17 I .V ,
COCOHATCHEE RIVER MARINA
t',„* Z 1 2012
(TOTAL PERMIT FEES NOW DUE: $140.00 I FINANCE
IIIIII'IIIIII IIlI IuI I.11.-.11„.
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
PO BOX 6720
FDACS-14326 Rev. 09/12 TALLAHASSEE, FL 32314-6720
,F 0002 II 0000321486 0 0000000000 0 0001426633 5 0000014000 7
The Department of Agriculture and Consumer Services, under authority of Chaper 500, Florida Status s t X si
regulatory and permitting authority for any person, business or corporation engaged in manufacturin s g, ac g,
holding or preparing food or selling food at wholesale or retail. Operating a Food Establishment without a current Food Permit
is a violation of Chaper 500, Florida Statutes, and is punishable by a fine of up to $5,000. For purposes of this application,
. "food" is considered to include, but is not limited to, all prepackaged foods, prepared foods, packaged ice, bottled water, candy
and other snack foods, soda, infant formula, and vitamin or mineral dietary supplements.
I If the business identified on the reverse side has been transferred to a new owner please call (850)245-5520 for
information on how to obtain a correct Food Permit. Do not return this Payment Coupon or the payment when the
business has been transferred to a new owner.
The business identified on the reverse side must obtain or renew its Food Permit, as follows:
1. Please review the Business Information and the Owner Information shown on the reverse side, and provide any
corrected or missing information in the spaces below, and
2. Separate and return the Payment Coupon payment for the amount shown as TOTAL NOW DUE, using the return
envelope provided OR remit payment online with coupon at www.FreshFromFlorida.com.
3. If you manufacture and/or package ice for sale, or if you bottle water for sale, you must also submit in writing with the
Payment Coupon:
a. Source(s) of water used.
b. Any treatment provided to ice prior to packaging.
After the Department receives the payment coupon and payment, your Food Permit will be mailed to the address shown under
Owner Information on the reverse side of this application.
However,
If your most recent inspection by the Department's Division of Food Safety resulted in a Sanitation Rating of "Poor
or if your firm has any outstanding balances due(such as: unpaid permits, unpaid administrative fines, unpaid re-
inspection fees, or outstanding returned checks*), you are not in compliance with statutory requirements. Your food
permit will not be issued until your sanitation rating and all payments are in compliance.
Payment for your Food Permit is due immediately. All Food Permits expire on December 31. It is your responsibility to renew
your Food Permit each year prior to expiration. Return this completed application and your payment immediately, to assure the
issuance of your Food Permit.
The Department will assess an additional fee of $100 for late payment.
* If the "business information" section of the revere side states a "Firm Status" of "RTD CHECK" this means that a
check previously submitted by you has been dishonored by your bank. All payments will first be applied to cover
the outstanding returned check. You will not be issued a Food Permit until all past due accounts are paid in full.
This application must be signed by the applicant, owner or chief executive of the applicant, without the need for
witnesses. If a corporation is in the hands of a receiver or trustee,this application shall be executed on behalf of the
receiver or trustee.
„Corrected BugfromThanyAon Corrected Owner Information
Name
Address
City/State/Zip Code
Phone
Owner email: Owner FEIN:
Department use Only
t sTt,,
By my signature below, I certify that I am empowered to execute this application aer=• • ed,by Chapter 500, Florida Statutes.
(Approved as to form&legal sufficiency ;., °, .d ,� Coa. \ \7 _- 'if-,11 4, t--1.. -'.,,--_,
7' . i F 3 W./ C - ewe; _ VV Ap,�Vs LIP°4, D11111 ►«�1. Printed Name DWIGHTE.BROOK,GLERK
cor n iGreene,
Assist. County Attorney ; ; •
The Department of Agriculture and Consumer Services, under authority of Chaper 500, Florida tatute is he cle�ff iv
regulatory and permitting authority for any person, business or corporation engaged in manufact ring, o e 't p ki � I
holding or preparing food or selling food at wholesale or retail. Operating a Food Establishment itho �jj pP�
is a violation of Chaper 500, Florida Statutes, and is punishable by a fine of up to $5,000. For pu poses of this application,
"food" is considered to include, but is not limited to, all prepackaged foods, prepared foods, pac aged ice, bottled water, candy
and other snack foods, soda, infant formula, and vitamin or mineral dietary supplements.
If the business identified on the reverse side has been transferred to a new owner please call (850)245-5520 for
information on how to obtain a correct Food Permit. Do not return this Payment Coupon or the payment when the
business has been transferred to a new owner.
The business identified on the reverse side must obtain or renew its Food Permit, as follows:
1. Please review the Business Information and the Owner Information shown on the reverse side, and provide any
corrected or missing information in the spaces below, and
2. Separate and return the Payment Coupon payment for the amount shown as TOTAL NOW DUE, using the return
envelope provided OR remit payment online with coupon at www.FreshFromFlorida.com.
3. If you manufacture and/or package ice for sale, or if you bottle water for sale, you must also submit in writing with the
Payment Coupon:
a. Source(s) of water used.
b. Any treatment provided to ice prior to packaging.
After the Department receives the payment coupon and payment, your Food Permit will be mailed to the address shown under
Owner Information on the reverse side of this application.
However,
If your most recent inspection by the Department's Division of Food Safety resulted in a Sanitation Rating of "Poor",
or if your firm has any outstanding balances due(such as: unpaid permits, unpaid administrative fines, unpaid re-
inspection fees, or outstanding returned checks*), you are not in compliance with statutory requirements. Your food
permit will not be issued until your sanitation rating and all payments are in compliance.
Payment for your Food Permit is due immediately. All Food Permits expire on December 31. It is your responsibility to renew
your Food Permit each year prior to expiration. Return this completed application and your payment immediately, to assure the
issuance of your Food Permit.
The Department will assess an additional fee of $100 for late payment.
* If the "business information" section of the revere side states a "Firm Status" of "RTD HECK" this means that a
check previously submitted by you has been dishonored by your bank. All payments wi I first be applied to cover
the outstanding returned check. You will not be issued a Food Permit until all past due accounts are paid in full.
This application must be signed by the applicant, owner or chief executive of the applicant, without the need for
witnesses. If a corporation is in the hands of a receiver or trustee,this application shall be executed on behalf of the
receiver or trustee.
Corrected Business Information ' t Correct
Name
Address
City/State/Zip Code
Phone
Owner email: Owner FEIN:
Department use Only
By my signature below, I certify that I am empowered to execute this application as r uired by Chapter 500, Florida Statutes.
i , , Approved,as to form&legal sufficiency
-�`✓!
Fred Wt✓ Chai ma 1--1-1. r\- 2-'=7 _
',�'� ! Printed Na Do•Applicant I/jr .�army WIGHT BROCK,CLERK
Coilee Greene, �V(/ ; liJdUl. , a,. o Cf,
Assistant County Attorney —_ . _.i estrum Ida.dt
, /AI, , ,
Florida Department of Agriculture and Consumer Servio1s6 D 31
Division of Food Safety j,
{@i i'"_ .ec,- Remit Food Permit fee online at:
f� 'T R www.FreshFromFlorida.com -OR- Send
s� _ ::.z- FOOD PERMIT APPLICATION Check or Money Order payable to FDACS
!.t. . -.4, in enclosed envelope to:
Chapter 500, Florida Statutes FLORIDA DEPARTMENT OF AGRICULTURE AND
ADAM H. PUTNAM Y CONSUMER SERVICES
COMMISSIONER (850) 245-5520 Po Box 6720
TALLAHASSEE, FL 32314-6720
2013 FOOD PERMIT NOTICE October 25, 2012
..1.1III'IJIIIIIII.IIII�I,1,..-Il"iliIlIll'IIIIill,IIiIIIlJi. I ,I
BOARD OF COMMMISSIONERS COLLIER COUNTY OCT 3 0 2012
15000 LIVINGSTON RD Parks and Recreation
NAPLES, FL 34109 - 3808
Sr 129 4S/fill Z B 3
////9//2, .
Permit Year Type: Permit Fee Epidemiology Late Fee Amount Paid Balance Due
Fee
2013 R $475.00 $10.00 $485.00
TOTAL NOW DUE: $485.00
BUSINESS INFORMATION for Firm No. 326436 OWNER INFORMATION
PORT OF THE ISLANDS MARINA BOARD OF COMMMISSIONERS COLLIER COUNTY
525 NEWPORT DR 15000 LIVINGSTON RD _
NAPLES, FL 34114-9648 NAPLES, FL 34109-3808 r'p '
Sanitation Rating: GOOD as of 09/08/2011 FEIN: 59-6000558 - Z
Firm Status: ACTIVE Business Type: BUSINESS
Firm Type: CONVENIENCE STORE W/SIGNIFICANT FOOD SERVICE Phone: (239)252-4000 v c
m
L2 G D Infil
The Department will issue a Food Permit after receipt of the required fees and the completed application (reverse iele),°
and will mail the permit to your business address. Return your completed application and payment by December 101 ; C
This will insure issuance of your permit by December 31, 2012. All 2012 Food Permits expire on December 31, 20 . R on
o' L°
FDACS-14326 Rev.09/12
Carefully tear along the perforation,and mail the signed coupon(bottom portion)and your payment in the envelope provided OR
remit payment online with coupon at www.FreshFromFlorida.com.
f Please use the reverse side of this coupon to provide any additional Business or Owner information,
or to make any changes to the information shown above.
The signature of an authorized individual must be provided on the reverse side of this coupon.)
October 25, 2012
2013 FOOD PERMIT NOTICE FOR FIRM NO. 326436 RECEIVED
PORT OF THE ISLANDS MARINA
E: 'v 21 2012
'TOTAL PERMIT FEES NOW DUE: $485.00 I yy AA,, E
IIJIII'IIIIIIIIIIIIIIIII.I.Iliiiiii'll'1II'il' 1.01llli1iI'lulll
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
PO BOX 6720
FDACS-14326 Rev. 09/12 TALLAHASSEE, FL 32314-6720
I ir. + 0002 4 0000334725 8 0000000000 0 0001430894 9 0000048500 7