GOSPICl`t`d q ^C�,Qui�cfa
1111111 VIII 1111 III1
71
BUS. LIC. NO.
1994 BUSINESS LICENSE APPLICATION FORM
*APPROVED BY Y •
* DATE
...... PROOF OF WORKERS COMPENSATION INSURANCE *IS"REQUIRED .'.y.y...,****#
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES
NO
2. Business Name: k10 T ,(TQC? V-4( L *tR 7-4
3. Business Address: -77-,; 00 N1C1qIGA1V 4. Mailing Address : _ 2,/0 8 OX eel
5. Business Phone : (- �p� �1 ) S —
6. Owned By: CORPORATION PARTNERSHIP (:Iii�VIDU
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Social Security # q— 40t - 7(/
9. Name of Owner / /� Q 5 �� C
• Title:
Or Officers
10. Type of-. Business: _Q 4
11. IF YOU ARE A FOJE
ENDOR, DO YO AVE A COUNTY HEALTH PERMIT:
S 0. NO
12. SBE Redale Number: ENC 9 9S7 3856
13. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To
Building Contractors):
A. Estimated Gross Business Receipts for New Businesses Only:
B. Previous Year Gross Receipts For Established Businesses:
i
"""*""**GOOD ONLY FOR JANUARY 1 1994 THRU DECEMBER 31,1994*******
I HEREBY CERTIFY that all the information supplied by me is correct and
any licenses required by the County, State or Federal Government have been
is ed to me at are in full force and effect.
n _d
Signature Title Date
Submit Form To: -
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
wn ..... - --
__.
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY `
e'`•. DEPARTMENT OF ENVIRONMENTAL HEALTH
FOOD FACILITY INSPECTION REPORT
('
Based on an inspection this day, the items identifi to iolations in structural or operational requirements
which must be corrected by the next routine ins i uch shorter period of time as may be specified in writing.
Failure to comply with any time limits for correction pecified in this notice may result iq cessatiorf of your fopd
re t• facility operation. The Department of Health p ec' tes your co e�tion. Public health protection Is everyone s
responsibility.
ESTABLISHME T N ME
PHONE DAT
TIME IN
L0C7ATAQ)N /
TRIC,,T
REINSPE TI f t&t L01t
OWN A / AC VIT & SE I COD E T FI
MAILING ADDRESS ()
f
_ /411e,
J 7v l �`'I (!' C1� y Cu
PERMIT Q� G D BY
NO.TOE:
EXP
TIME OUT
DESCRIPTION OF ITEM
VALUE
�fJST
D— 77T
`� REMARKS
1. FOOD: Approved source j4No
spoil ege/contamination 4; Not reused 4;
Properly Stored 2; Properly protected 4;
...............,
/
v' ^ (1 �1� _ r c Ar)
Use or sulfites 2; Properly labeled
2. -TEMPERATURE CONTROL: Poten—
tially hazardous food below 45' F 7• or
above 140OF 1; Refer thermometer 1;
P!obe thermometer 2; Food properly%':!':,;.
n e <'{,7, 7— C� l ( �.
thawed 4; Frozen food maintained
frozen or not refrozen 1.
/
L• Q - C
`
3. PERSONNEL; Foodhandler cards t-0,),G%�e��.
Personal hygiene 5; Clean clothes 2;
Food handling 2; Hair restraint 2; No
smoking 3; Clothing storage 1.
4. WATER & SEWAGE: Hot and cold
potable water under pressure j; Liquid`<:t.....j'...;
este disposal 3; Plumbing In good
air 3; No cross connections 2.
,
j[ ,(�
(�
/
t
/'� �� ' O r �(1 r P (y / 1
5. _QUIPMENT: Maintained In clean
condition 16; Maintained In good'•
repair 10; Properly protected 4;Vz
Approved 3.
t
,
iC � C�rC -
6. UTENSILS: Proper washing N Proper
sanitizing 1; Clean 1; No damage.?;
Properly stored 3i Testing Material
provided ;.
Q
;''fJ:i:,
P i
/� `t `.
Cf G1 e t
7. FLOORS: Clean 2; Good repelr
WALLS & CEILING/WINDOWS &
,
SCREENS: Clean 2; Good repair 2;
Light color 1.
S. TOILET/DRESSING ROOM &HAND
SINKS: Good repair 3; Clean 3;
Self-closing doors 1; Hand cleanser 4;
Towels 3; Proper dispensers 2; Toilet
/,k ;p Cfr—f
tissue 2; Hand wash signsl,.Properly
vented . Adequate L
!
-LIGHT9. & VENTILATION: Adequate 3,
Exhaust filters 2; Functioning 2;
ILIr0170:74.1
Fixtures protected 1.
I0. PEST CONTROL: No Insects !: No
rodents 1; No animals or birds g; Outer
..............
(
openings protected 2; Self-closing
outside doors 1.
11. REFUSE: Properly stored 1; Containers
cov' ered 1; Adequate 2; Clean j;
(Qj
Surrounding: clean 1.
12. OPERATION: Toxics labeled and
separated 1; Living & sleeping quarters
.......,,.
'
separated 1; Signs posted 1;Cleanitng
equipment storage 1; Proper linen
storage 1; Spoils area maintained 2.
POINTS POSSIBLE 200— POINTS LOST-:' 2 = TOTAL SCORE
This facility is required by local Ordinance to dis lay a grade card in a conspicuous place selected by the Enforcement Officer. The grade card shall
not be concealed and can only be removed by the enforcement Officer.
GRADES REPRESENT THE FOLLOWING SCORE RANGES: A = 100-90, B >= 89-80 and C = 79-0.
RIVERSIDE HEMET PERRIS BANNING PALM SPRINGS INDIO BLYTHE TEMECULA
358-5172 768-2478 867-0738 849-8794 778-2235 342-8287 922-8158 894-5022
Doli-ammm'111% Orig.— Office 1st Copy — Owner 2nd Copy — Office Page _of _Papeu,
o r a� `� COUNTY OF RIVERSIDE
`y •
HEALTH
f'• t 9
SERVICES AGENCY
DIFA, SIDE HEALTH SERVICES AGENCY
- DEPARTMENT OF ENVIRONMENTAL
HEALTH
u 7 . `= „°, DISTRICT ENVIRONMENTAL
SERVICES DIVISION
T OF ENVIRONMEEN TAL HEALTH
ITY INSPECTION REPORT
SANDY TOSCH, R.E.H.S.
items identifi to iolations in structural or operational requirements
ENVIRONMENTAL HEALTH SPECIALIST III
•
routine ins i uch shorter period of time as may be specified in writing.
for correction pecified in this notice may result iq cessation of your fopd '
Health p rec tes your co e�tion. Public health protection Is everyone s
INDIO OFFICE
'
PHONE: (6+9)863.8287 47-923 OASIS STREET
ID. CA 9220,
FAX: (619)863-8320
PHONE - DAT N
TIME IN
i,
�� repyG�Ctl paper
t_tn.w t ry / v
Z / X /`�
TR!T REINSPE T
t?�
/
OW0�/
AC VI & SE I COD E ��FOJL
P !0._
MAILING ADDRESS (f
/J
�[/ /�
�
D BY
NO.
PER T Q� XP
TIME OUT
70 A
C
�
r!'C{�
tr
EXP :
DESCRIPTION OF ITEM
VALUE
�osT
`� REMARKS
1. FOOD: Approved source 4: No
spollage/contamination 4; Not reused %
ti
/
Properly stored 2; Properly protected 4;
.i':>.
r
Use of sulfites 2; Properly labeled 1,
c
2. TEMPERATURE CONTROL: Poten—
tially hazardous food below 4S' F _ or
�7 r
above 1400F 2; Refer thermometer 1;
�' n �,.t,L/f' ( w,
Probe thermometer 2; Food properly
thawed 4; Frozen food maintained
frozen or not refrozen 1.
3. PERSONNEL; Foodhandler cards 1;C1/
C
Personal hygiene 5; Clean clothes 2;
Food handling 2; Halt. restraint 2; No
smoking 3; Clothing storage 1.
/
4. WATER & SEWAGE: Hot and cold
potable water under pressure j; Liquid
waste disposal 3; Plumbing
4 �`
In good
repair 2; No cross connections 2.
5. EQUIPMENT: Maintained In clean
i �C'
condition 16; Maintained In good
repair 10; Properly protected 4;
-
-,
/10
Approved 3.
6. UTENSILS: Proper washing N Proper
sanitizing 1; Clean 3; No damage.?;
Properly stored 2; Testing material
P
r o .�? �5� rdi
provided JL.a
7. FLOORS: Clean 2; Good repair 2.
�� / L t L1 > ,/— r /1
WALLS & CEILING/WINDOWS &
SCREENS: Clean 2; Good repair 2;
^`
Light color 1.
/O_ Or _ap efp
8. TOILET/DRESSING ROOM & HAND
SINKS: Good repair 3; Clean 3;
/
Self-closing doors 1; Hand cleanser 4;
-
Towels 3; Proper dispensers 2; Toilet
(Issue 2; Hand wash signs 1.Properly
vented Adequate 1.
I
rT f T &VENTILATION: Adequate 3
Exhaust filters 2; Functioning Z;
i
��� '. ( +�(^�•'�llj �'
Fixtures. protected 1.
"`>
y
10. PEST CONTROL: No Insects !; No
rodents 9i No animals or birds 4; Outer
�•
openings protected 2; Self-closing`��VS>.
outside doors 1.
l rGl�l '
11. REFUSE: Properly stored 2; Contalnen
covered 1; Adequate 2; Clean 1;
Surrounding: clean 1.
12. OPERATION: Toxics labeled and
separated 1; Living & sleeping quarters
^..,..."
separated 1; Signs posted 1; Cleanlog
equipment storage 1 Proper linen
storage 1; Spoils area maintained 2.
POINTS POSSIBLE 200—
POINTS LOST-' 2 = TOTAL SCORE
This facility is required by local Ordinance to display a grade card in a conspicuous place selected by the Enforcement Officer. The grade card shall
not be concealed and can only be removed by the Enforcement
Officer,
GRADES REPRESENT THE FOLLOWING SCORE RANGES: A = 100-90, B = 89-80 and C = 79-0.
RIVERSIDE HEMET PERRIS
BANNING PALM SPRINGS INDIO BLYTHE TEMECULA
358-6172 '766-2478 657-0738
849-6794 778-2235 342-8287 922-8158 694-5022
Dwt•sAr+tr>a(nevl)a
Orig.— Office
1st Copy a Owner 2nd Copy — Office Page_ of _f'pliuo.
r
Mike Halbert
Store Manager
WAL* MART°
STORES, INC.
Store 1805
78-950 Hwy. 111
La Quints92253 •
"PPiHfED OH PEDYCLED P�VEP 611 59 584-3313
•