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ADDENDUM # FP1 - Application for Food Permit
Please type or print in dark ink
BLANK SPACES ARE NOT PERMITTED. IF ANY ITEM IS NOT APPLICABLE, OR NO INFORMATION IS
AVAILABLE, THE SPACE MUST BE MARKED TO INDICATE THAT. INCOMPLETE AND/OR ILLEGIBLE
APPLICATIONS WILL BE RETURNED TO APPLICANT.
The Tulalip Tribes of Washington
Community Development Department
TAX & LICENSING DIVISION
6406 Marine DR NW
Tulalip, WA 98271
Telephone: (360) 716-4204
FOR OFFICIAL USE ONLY:
FOOD PERMIT No.
BUS LIC NUMBER
APPLICABLE YEAR
HEALTH INSPECTOR RECOMMENDATION: APPROVE DENY
INSPECTION DATE: ____/____/____ INSPECTOR: ________________________
Reason for denial: _____________________________________________________
________________________________________________________________________
# MINOR OFFENSES: ________ # MAJOR OFFENSES: ________
Application Approved with SPECIAL CONDITIONS: Yes (Attach) N/A
CHECK / MONEY ORDER #
RECEIPT NUMBER
TLD COMMENTS:
PAYMENT SUMMARY FEE
forms of payment are cash, check, and money order made payable to The Tulalip Tribes / TLD.
License fees are not pro-rated and are nonrefundable
. Please choose:
NEW ESTABLISHMENT NEW OWNERSHIP RENEWAL
APPLICATION FEE $
10.00
INSPECTION FEE(s) $
TOTAL AMOUNT PAID $
Facilities used less than 25 days per year and seasonal vendors $30.00
Submit the following with application:
1.) Floor and equipment plans (to scale drawing new
app
licants, and remodels)
2.) L & I Inspection (Mobile Units)
3.) Copy of current menu – indicate if menu changes
seasonally, provide sample or explanation
4.) Employee Sanitation Safety Plan
5.) Food Handler’s Cards
6.) Application and Inspection Fees
Class “A” Seating Capacity 126 and Over $ 200.00
Class “B” Seating Capacity 51 – 125 $ 125.00
One Day or Less $ 10.00
Two or Three Days $ 15.00
Four to Seven Days $ 25.00
GENERAL INFORMATION
Firm/Trade Name
Business Mailing Address ( Street or Route, P.O. Box, Suite # - Do not use building name)
City
State
Zip
Business Telephone Number
( ) -
Physical Business Location, if different from above (Street or Route, City, State, Zip)
FAX Number
( ) -
County
Your Federal I.D. Number (FIN)
Total number of business location’s you have on
the Tulalip Indian Reservation
Is this Business
Part Time Full Time
Number of Employees:
NEW ESTABLISHMENT / NEW OWNERSHIP: Date you plan to open/take over business: / /
Water Source (check one) Public Well Sewage Disposal (check one) Public Sewer On-Site
Seating Capacity: _________ Facility Size (Sq Ft): _________
REWEWAL :
Has there been, or do you plan on any remodeling: No Yes If Yes, please attach items 1, 2, and 4 from Section A, above
NOTE: New and remodeling food establishments must submit two copies of floor and equipment plans to be filed with the Tax & Licensing Division and Tulalip Health
Inspector and obtain any required permits under Tulalip Land Use Title 7. Please allow 3-
4 weeks for Health Inspector plan review prior to building, etc. to ensure plans are
adequate, or allow for modifications that may be required. Applicant is responsible for scheduling pre-opening inspection with Tulalip Health Inspector by contacting Vince
Cooke at 360.716.5129. DO NOT OPEN WITHOUT TULALIP TRIBES / IHS APPROVAL
A
B
Food Permit App Revised 03/2014
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“MOBILE” BUSINESS Do
primary business activities include the operation of a vehicle / mobile unit traveling from place to place to offer sale of products?
YES NO
If yes, attach a copy of a valid WA State Drivers License for each person operating vehicle / mobile unit within the exterior boundaries of the Tulalip Reservation,
and a separate sheet providing description of all vehicles / mobile units used for this purpose. Description shall include at minimum the make, model, year, license
number, color, and affixed signage, advertisement, and/or other identifying marker for each vehicle / mobile unit.
Please check box that best describes this business:
On-site Preparation – Permanent establishment
On-site Preparation – Temporary establishment
Catering – Attach description of prep location and methods
Delivery only of food items prepared at an off-reservation establishment
On and Off-site Preparation – Attach description of prep location and
methods
Pl
ease check box that best describes this business:
Child or Adult Care Facility Community Kitchen
Public School Government or Nonprofit Facility
Restaurant Bar/Lounge/Club
Grocery/Convenience Store Seasonal Produce
Temporary Vendor - Provide dates below
Start: ______________________________ End: ______________________________
Hours of Operation:
M _____:_____ to _____:_____ F _____:_____ to _____:_____
T _____:_____ to _____:_____ S _____:_____ to _____:_____
W _____:_____ to _____:_____
Su _____:_____ to _____:_____
Th _____:_____ to _____:_____
Total # of Employees: ________
Food Handlers: ________ Deliverers: ________
Min. staff per shift:
________ Max. staff per shift: ________
HANDLING, COOKING & TEMPERATURE CONTROL METHODS
(i.e. Stove Top, Wok, Deep Fryer, Steamer, Oven, Smoker, BBQ, Gas Grill, Microwave, Hot Case, Steam Table, Refrigerat
or, Ice, Ice Bath, Freezer)
How Will Potentially Hazardous Food be Thawed?
Thawing Method Food less than 1” thick Food more than 1” thick
Refrigeration ___________________ ___________________
Running water (<70ºF) ___________________ ___________________
Microwave ___________________ ___________________
Cook from frozen ___________________ ___________________
Other: ___________________ ___________________
Explain how food will be handled during transport: __________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Method for cooling food (45°): Ice Bath Refrigerator at 2” to 4” Depth
Other: _____________________________________________________________
Cooking & Reheating Potentially Hazardous Food
List all cooking & reheating equipment and check all applicable boxes:
Equipment Name: Cooking Reheating Frying Other
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Hot and Cold Holding of Potentially Hazardous Food
List all hot & cold holding equipment and check all applicable boxes.
Equipment Name: Hot Cold
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Eliminating contact with food with bare hands:
Disposable Gloves Utensils Bakery Tissue Other (list) ____________________________________
Will ice be used as a refrigerant for potentially hazardous foods? Yes No If yes, describe food types, duration, where this will occur, and the source of the ice.
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
ADDITIONAL INFORMATION
TERO COMPLIANCE PLAN TERO (360) 716-4747
Tulalip TERO Title 9 #9.05:
TERO is the Equal Employment Opportunity Commission Representative (EEOC) on the Tulalip reservation. Tulalip TERO laws
and ordinances enforce specific requirements upon businesses, contractors, and subcontractors doing business within the exterior boundaries of the Tulalip
Reservation including regulating their employment practices and obligating them to provide preference in recruiting, hiring, training and promotions to certified
Native Americans.
QUIL CEDA VILLAGE / TRIBAL GAMING AGENCY
QCV: Businesses and vendors operating within the boundaries of the Consolidated Borough of Quil Ceda Village (QCV) are required to enter into a lease agreement
and/or obtain a special operators license. For more information, contact the QCV Business Park at 360.716.5000.
TGA: Vendors providing services at or for any of the Tulalip Casino or Bingo entities are required to obtain a vendors license issued by the Tribal Gaming Agency
(TGA). For more information, contact the Tulalip TGO Office at 360.716.2000.
CIGARETTE, LIQUOR, FIREWORKS, BUSINESS, AND TRANSIENT ACCOMMODATIONS LICENSE REQUIREMENTS
Tulalip Tribes Cigarette Title 12 #12.10: LICENSE REQUIRED
Tulalip Tribes Liquor License Title 10 #10.35 and Tulalip Liquor Regulations: LIQUOR LICENSE(S) REQUIRED
Tulalip Fireworks Code Title 10 #10.25:
WHOLESALE AND RETAIL LICENSE(S) REQUIRED- Sale of retail fireworks in Tulalip is restricted to enrolled
members of the Tulalip Tribes of WA; sale of wholesale fireworks is unrestricted.
Tulalip Tribes Business License Title 10 #10.10: BUSINESS LICENSES ARE REQUIRED FOR ALL BUSINESSES OPERATING OR PROVIDING
SERVICES WITHIN THE EXTERIOR BOUNDARIES OF THE TULALIP RESERVATION.
Tulalip Tribes Transient Accommodation Ordinance Title 10 #10.40: LICENSE REQUIRED
C
D
Food Permit App Revised 03/2014
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INDIAN TRADERS LICENSE
For information pertaining to Indian Trader’s Licenses, please visit/ contact the Bureau of Indian Affairs, Puget Sound Agency at:
2707 Colby Avenue, Suite 1101, Everett, WA 98201 - (425) 258-2651
SUPPLEMENTARY DOCUMENT REQUIREMENTS
The Tax & Licensing Division may require proof of insurance, tribal enrollment, certification, permits, contracts, other licensure (local, county, state, and federal),
vehicle registration, criminal background investigation, and additional information and/or documentation as defined in Tulalip Business License Title 10 #10.10
HEALTH INSPECTIONS: All new food facilities and vendors must pass inspection by the Tulalip Tribes Environmental Health Inspector BEFORE
providing any services that include food and/or beverage items for human consumption. Established facilities and vendor are subject to an annual
inspection upon expiration of any permit or license issued pursuant to Tulalip Food Service Sanitation Title 11 #11.20.
FOR MORE INFORMATION OR TO SCHEDULE AN INSPECTION CONTACT MIKE COONEY AT 360.716.5066
INCOMPLETE AND ILLEGIBLE FORMS WILL NOT BE ACCEPTED / PROCESSED
Incomplete and/or illegible applications and/or failure to remit fee or required supplemental documents are not accepted and may result in penalty fees.
SIGNATURE REQUIRED
(Sole proprietor, partner(s), corporate officer(s), limited liability manager(s), or member(s))
Your signature attests to the accuracy of the information provided and that your business will comply with all applicable Tribal and Local Laws
BY SIGNING BELOW, I UNDERSTAND AND AGREE TO THE FOLLOWING:
I DECLARE THAT I HAVE EXAMINED THIS APPLICATION AND THE INFORMATION CONTAINED HEREIN, AND TO THE BEST OF MY
KNOWLEDGE AND BELIEF, IT IS TRUE AND CORRECT. I SWEAR OR AFFIRM THAT I WILL COMPLY WITH ALL TRIBAL LAWS APPLICABLE TO
MY BUSINESS AND CONSENT TO THE JURISDICTION OF THE TRIBAL COURT OF THE TULALIP TRIBES AND SERVICE OF PROCESS IN
MATTERS ARISING FROM THE CONDUCT OF BUSINESS.
Signature
X
Printed Name
Title
Date
Signature
X
Printed Name
Title
Date
Application prepared by (Indicate if prepared by other than authorized owner, officer, manager, or member)
Telephone Number
( ) -
Signature of Preparer
X
Title
Date
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Food Permit App Revised 03/2014
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Completed 20 July 2020

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