HomeMy WebLinkAboutCava Mezze Grill Operating Permit 2024-2025 r
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1982 BUILDING DEPARTMENT
❑BUILDING INSPECTOR
''ASSISTANT BUILDING INSPECTOR VILLAGE OF RYE BROOK
❑CODE ENFORCEMENT OFFICER 938 KING STREET • RYE BROOK,NY 10573
(914) 939-0668 FAX (914) 939-5801
www.ryebrook.org
- - - - - - - - - - - - - - - - - - - - INSPECTION REPORT - - - - - - - - - - - - - - - - - - - -
*A 'p
ADDRESS : 'r G e\ I v4 G DATE:
PERMIT# �!�- T�SI CC�u-ISSUED: SECT: BLOCK: LOT:
LOCATION: {�/-f /•/ 2 / �,�� C- OCCUPANCY:
❑ VIOLATION NOTED THE WORK IS... [a ACCEPTED ❑ REJECTED/ REINSPECTION
❑ SITE INSPECTION REQUIRED
❑ FOOTING
❑ FOOTING DRAINAGE
❑ FOUNDATION
❑ UNDERGROUND PLUMBING NOTES ON INSPECTION:
❑ ROUGH PLUMBING
❑ ROUGH FRAMING
❑ INSULATION
❑ NATURAL GAS
❑ FUEL GTANK
❑ FIRE SPRINKLER
❑ FINAL PLUMBING
❑ CROSS CONNECTION
❑ FINAL
❑ OTHER
BUILDPBROO
TMENT1,, `IVILL OOOKInitial Inspection Date: ❑ Pass
NZ" PA&b k�- 938 KING ST RY Ew YORK 10573 2 '70Z3 Fail
BUILDING&FIRE INSPECTOR (914)9 rook.Or Re-Inspection Date: ❑ Pass
mizzo@rvebrook.or;? ��, �- ��_ Z OL � ❑ Fail
FIRE INSPECTION REPORT, NOTICE OF VIOLATION & ORDER TO REMEDY SAME
Site Address: 3 4 5 ��y,:-, (J' \j ?LA Z G Zone: SBL:1 Y
Occupancy: CA ✓A State Use Classification:
Business Owner: LAMA YY1 f Z Z C 6 t-1 �� Le'.C-o Phone:20L - y007' 1 2j�
Building Owner: IAI I nJ Z 1� C Qc..` L L C Phone: /l`r- 70 - yQasr
Emergency Contact: Z A P Phone: Z Q l` Q� E F
Building Representative in Attendance: ZJr6 C'Q ^!o44w,XL " Yo 1 -+ ' 7 7,87
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Take notice that the following violations of the New York State Uniform Fire revention&Building Code and/or the Code of the
Village of Rye Brook were found to exist at, GA ✓A M E Z 2 E 6-ki LL 2 e 2ld P�.f I'l ,in the Village of
Rye Brook,NY on, e C e ,5 u� J q 20 The person or entity served wi this Order to Remedy shall
immIAiaN1U commence t prre je listed violations and shall completely cure each violation described herein by no later than
which is thirty(30)days after the date of this Order to Remedy.Furthermore,
upon curing any listed violation(s),you shall immediately contact the Building Department during normal business hours to schedule a
re-inspection of the premises to confirm full compliance with all applicable codes,laws,rules®ulations.
BE ADVISED THAT YOUR FAILURE TO CORRECT ALL VIOLATIONS IS A CRIME PUNISHABLE BY FINE,IMPRISONMENT OR BOTH.
------------------------------------------------------------------------------------------------------------------------------------------------------------------
NO YES N/A
1.PORTABLE FIRE EXTINGUISHERS (PFE's)
a.906.1. Are PFE's installed throughout the space&on the premises as required by code. a.
b.906.3.1.Is the maximum travel distance to a PFE 75 feet or less. b._
c.906.5.Are PFE's conspicuously located&readily accessible. C._ ✓
d.906.6.Are PFE's unobstructed/unobscured from view. d.
e.906.7.Are PFE's properly mounted as per the manufacturers instructions. e.
f.906.9.Are PFE's properly installed:<40 lbs.max.5'above floor;>40 lbs.max.3.5'above floor. f._
2.FIRE ALARM SYSTEM&SMOKE DETECTORS
a.901.6.1.Is the fire alarm system inspected,tested&maintained in accordance with NFPA 72. a.
b.907.4.2.1.Are manual pull stations located within 5 feet of exits&within 200 feet of each other. b.
c.907.4.2.2.Is the height of the pull station handle located between 42&48 inches above the floor. c._ V
d.907.3.Is a fire alarm system provided in existing buildings as per section 907.3.1 &907.3.2. d.
3.FIRE SUPPRESSION SPRINKLER SYSTEM&FIRE HYDRANTS
a.901.6.1.Is the sprinkler system inspected,tested&maintained in accordance with NFPA 25-13. a.
b.901.6.1.Are the main valves secured against tampering in the open position. b.
c.901.6.1.Are sufficient clearances maintained from fire sprinkler heads to fixtures or materials. C.
d.901.6.1.Is a supply of six spare heads&a wrench maintained on the premises. d.
e.901.6.1.Are sprinkler heads&cover plates unfinished or of factory applied finish only. e.T
f.901.6.3.Are records of all system inspections,tests&maintenance reports maintained on the premises. f.
g.913.5.Is the fire pump inspected,tested&maintained in accordance with this section&NFPA 25. g.
h.507.5.2.Is the fire hydrant system properly maintained,operational,compatible w/NST&tested annually. h.
i.507.5.4.Are fire hydrants&fire protection equipment unobstructed. i.
j.507.5.5.Is a clear space of not less that 3 feet maintained around all hydrants. j.
k.901.8.Are all fire protection systems in place and maintained untampered. k.
INSPECTOR: C�a I DATE:
1-
Revised 2/10/22
No YEs N/A
4.STANDPIPE,CABINETS&FIRE DEPARTMENT CONNECTIONS
a.901.6.1.Is the standpipe system inspected,tested&maintained in accordance with NFPA 25-14. a. ✓
b.901.6.1.Has the required flow test been performed within the past 5 years as per NFPA 25-14. b. _
c.912.2.3 Are standpipe FDC threads compatible with fire department standards. C. i
d.905.7.Are cabinets containing fire fighting equipment unobstructed/unobscured. d. i
e.905.7.1.Are cabinets containing fire fighting equipment properly identified&labeled. e.
f.912.2.1.Are exterior FDC's fully visible&recognizable from the point of fire department access. f.
g.912.4.Are ail FDC's unobstructed and available for immediate access by the fire department. g.
5.EXITS,MEANS OF EGRESS&OCCUPANCY
a. 1031.2.Are exits&exit enclosures continuously maintained free from obstructions or impediments. a. ✓ y
b. 1031.3.Is the means of egress free from obstructions including accumulated ice&snow. b. Jw/
c. 1031.6.Are exits maintained unobstructed by furnishings,decorations,draperies,mirrors,etc... C.
d. 1031.7.Are existing emergency escape&rescue openings maintained as per this section. d. ✓ _
e. 1010.1.Are egress doors provided and maintained as required by this section. e.
f. 1004.9.Are all spaces having an assembly occupancy posted with an approved occupant load sign. f. V _ v
g. 1013.1.Are exits marked by a properly located,approved&readily visible exit sign. g.
h. 1013.1.Is the maximum travel distance to any exit sign in an exit access cohidor 100 feet or less. h.
i. 1013.4.Are tactile exit signs complying with ICC/ANSI 117.1.provided as required by code. i.
j. 1013.3.Are all exit signs illuminated at all times. j.
k.1008.1.Are the means of egress&exit discharge illuminated at all times the building is occupied. k. _
1. ){018.3.Are public aisles in group B&M occupancies maintained at least 36"wide where fixtures I.
are placed on one side`of the aisle&at 44"wide where fixtures are placed on both sides.
m. 1018.3.Are non-public/non-accessible aisles serving less than 50 people maintained at least M.
28"wide,or at least 36"wide where serving 50 or more people.
6.COMBUSTIBLE STORAGE&WASTE MATERIALS
a.304.1.Is the building(s)and premises maintained free from accumulated combustible waste material. a.
b.304.1.2.Is property free from weeds,grass,vines or other growth capable of being ignited. b.
c.304.2.Is combustible rubbish stored so as not to create a nuisance or hazard to the public. C.
d.315.3.Are combustible materials properly stored&separated from ignition sources. d. _
e.315.3.1.Is storage maintained 24"or more below the ceiling in nonsprinklered buildings, e.
and 18"or more below sprinkler head deflectors in sprinklered buildings.
f.315.3.2.Are exits&exit enclosures maintained free from stored combustible materials. f. _
g.315.3.3.Are boiler,mechanical&electrical rooms maintained free from stored combustible material. g.
h.313.1.Is building maintained free from stored fueled equipment.(motorcycles,mopeds,mowers,etc...) h.
7.ELECTRICAL
a.604.1."Is the building free from modified/damaged wiring,devices,appliances,equipment a.
and maintained free from electrical hazards.
b.604.2.Are electrical service equipment areas properly illuminated. b._ ✓ _
c. 604.3.Are proper working space clearances provided&maintained for electrical service equipment. C._
d.604.3.Are electrical service equipment working spaces free from any stored materials. d.
e.604.3.1.Are all electrical control panel room doors,panel boards&disconnects properly labeled. e.
f.604.4.Is the building free from unfused multi-plug electrical adapters. f
g.604.5.Are electrical extension cords being used in a safe manner as per code. g.
h.604.6.Are all junction,switch&outlet boxes fitted with approved covers or plates. h._ 1/
i.604.6.Is the building free from open-wiring spliced electrical connections.
j.604.8.Are electrical motors maintained free from accumulated oil,dirt&debris. j.
k.915.1.Are Carbon Monoxide Detectors installed&maintained as required by this section and by 1103.9. k._
INSPECTOR: DATE: Z / Z•�L3
-2-
Revised 6/11/2020
No YES N/A
8.ELEVATORS,DUMBWAITERS&ESCALATORS
a.[PM]603.1.Are elevators properly maintained,and is the current certificate of inspection on the premises. a. _ _ ✓
b.606.3.Are approved standardized,pictorial signs posted adjacent to each elevator call station on all b.
floors reading; IN FIRE EMERGENCY,DO NOT USE ELEVATOR,USE EXIT STAIRS
c.606.7.Are keys for elevator car doors&fire department service kept in an approved location. C. _ _ ✓
d.315.3.3.Are elevator machine rooms maintained free from stored combustible material. d.
e. [B]3005.1.Are elevator machine room doors maintained unobstructed at all times. e.
9.COMMERCIAL KITCHENS
a.906.1. Are portable Class K fire extinguishers installed within 30 feet of cooking equipment. a. _ ✓
b.904.12.5.Is the fire protection equipment inspected,tested&maintained as per Section 901.6. b.
c.904.12.5.2.Are automatic fire extinguishing systems serviced at least every 6 months. C. _
d.904.12.5.3.Are fusible links&automatic sprinkler heads replaced annually. d.
e.[RBI 122-5.B.Are grease traps provided and installed as required by Village Code. e.
f.[[Pc]1003.10.[RB]122-6.Are grease traps properly maintained as per State and Village Code. f.
g.[RB]122-6.C., 122-9.Are all service,maintenance,&repair records for grease traps and related
plumbing maintained on the premises as required by Village Code. g.
10.HEATING SYSTEMS
a. [PM]603.1.Are all heating appliances properly installed&maintained in a safe working condition. a.
b. [PM]603.2.Are all fuel-burning appliances&equipment connected to an approved chimney or vent. b.
c.[PM]603.3.Are heating appliances maintained with proper clearances from combustible material. C.
d. [PM]603.4.Are safety controls for fuel-burning equipment maintained in effective operation. d.
e. [PM]603.5.Is the fuel-burning equipment provided with adequate combustion&ventilation air. e.
11.MOTOR FUEL-DISPENSING FACILITIES&REPAIR GARAGES
a.2303.2.Is an approved,labeled&readily accessible emergency disconnect switch provided a.
in an approved location within 100'of,but not less than 20'from fuel dispensers.
b.2304.3.4.Are dispenser operating instructions conspicuously posted on every fuel dispenser. b.
c.2304.2.4.Are fuel-dispensers unobstructed&in clear view of the attendant at all times. C.
d.2305.5.Are approved portable fire extinguishers complying with Section 906 with a minimum rating of d.
2-A:20-B:C provided&located not more than 75'from pumps,dispensers&fill-pipe openings.
e.2305.6.Are warning signs provided&posted within sight of each dispenser as per this section. e.
f.2305.7.Are weeds and other combustible materials kept at least 10' from fuel-handling equipment. f. _
g.2306.4.Are above-ground tanks provided with vehicle impact protection. g. _
h.2306.5.Are above-ground tanks provided with secondary spill containment. h.
12.HAZARDOUS MATERIALS(HAZ-MATS)
a.407.2.Are S.D.S. Sheets for all haz-mats readily available on the premises. a.
b.407.3.Are spaces and individual containers containing haz-mats properly labeled&identified. b.
c.5004.2.Are stored haz-mats provided with approved secondary spill containment. C.
d.5003.7.1.Are proper NO SMOKING signs provided as per this section. d. _ ,L
13.MISCELLANEOUS
a.403.1. Is an approved fire safety&evacuation plan prepared&maintained for the building/occupancy. a.
b.405.1.Are emergency evacuation drills conducted at the intervals as specified in Table 405.2. b.
c.405.5.Are records of emergency evacuation drills kept&maintained on the premises. C. _
d.505.1.Are approved address&building numbers properly placed&plainly visible from the street. d. ✓_
e. 506.1.Are approved key boxes(knox boxes)provided,properly located&equipped with the proper keys. e.
f.703.1.Is all required fire-resistance rated construction properly maintained as per code. f.
g.703.1.Are openings through fire-resistance rated assemblies properly protected&maintained. g.
h.5303.5.Are compressed gas cylinders&systems secured&safeguarded against damage&access. h.
i.5303.6.1.Are compressed gas cylinder caps or collars in place at all times except when tanks are in use. i.
14.GENERAL HOUSEKEEPING
a.Good
b.Fair
c.Inadequate
d.Poor INSPECTOR:T �, 1� DATE: � Z -
-3-
Revised 9/17/21
ITEM NUMBER REMARKS
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INSPECTOR: � DATE: LoZ3
4-
�L�'�' I / O Revised 6/11/2020
t� r%; (\,� 4, \-" I -6-r-
ll, tr. Phone:585.720.0390
www.Empirefps.com
client:CAVA 10043 Rael Site#: Client WO#:
Address:3 Rye Ridge Plaza Date 08/24/2023 09:00am EDT
City:Rye Brook State:NY Zip:10573 Page of
Pre-Maintenance Housekeeping
Y N tilA Y N NH1
01 Has the hazard changed since last inspection? ✓ 01 Hood&duct clean r
02 Has the system discharged since last inspection? r 02 Hood meets NFPA 96 ✓
03 Exhaust fans operational ✓ 03 Fan warning sign installed ✓
04 Cylinder size M-3g S- S- S- 04 Fitters dean ✓
05 Cylinder hydro-test date 05 Filter proper size&installed correctly ✓
06 Cylinder serial number S4071905 06 Baffle We filter ✓
07 Cylinder location lockers 07 K class portable installed ✓
08 Manufacture Ansul 08 K class sign installed r
09 Model R-102 09 Portable serviced ✓
10 Deep fat fryer r 10 Date tagged oslzarza
11 All required appliances covered ✓ 11 All nozzle caps present Yes
Maintenance Post Inspection
01 Disarm system ✓ 01 System armed&operational ✓
02 Test fire system(link line) ✓ 02 Pilot lights relit ✓
03 Test fire manual release ✓ 03 MSDS sheet ✓
04 Gas valve shutdown ✓ 04 Owner's manual ✓
05 Electric power shutdown r 05 Occupants trained ✓
06 Make-up air shutdown ✓ 06 System tagged O Operational ❑Non-Compliant
07 Fire alarm activated ✓
08 System test fired property ✓ ✓ Comments
09 Check cable for damage ❑Replaced r any•No"answers,test failures or other system problems round must be explained here.
10 Conduit and pipe secure ✓
11 Hood penetrations per NFPA 96 ✓
12 Gauge in green PSI ✓
13 Cartridge replaced Size ✓
14 Nozzles dean and property aimed ✓
15 Manual release located between 10'and 20' r
16 Fusible links replaced(360) Oty_ ✓
17 Fusible links replaced(450) Qty 3 " 1 state that the information on this form is correct at the time and place of my inspection,
18 Fusible links replaced(500) Qty? ✓ and that all equipment tested was left in operational condition at completion of this
19 System is UL-300 compliant ,, inspection except as noted.
20 Test Link Qty_ Break rod Qty_ ✓ Signature of Inspector:
21 Rubber caps replaced Metal caps replaced_ ✓
08l24l2023 os:00am EDT
22 O-ring and Copper tubingin lace and dear Name:William Valentin Date;
23 Puff Test Performed ✓
Client Verification(Required):I hereby acknowledge the satisfactory completion of the above
described work.
Manager Signature
Print Name
Rina Chavez
WO# 157625
RAEL Trip: #1
NATIONAL Customer PO#:#245383872
Priority: Standard
SITE INFORMATION WORK ORDER CONTACT
Site Name: Cava-010043 Requested By: RAEL National
Site Address: 3 Rye Ridge Plaza, Rye Brook, NY Contact: Service@raelnational.com
10573, US Phone(s): +1 844-438-7235
Site Contact: Manager On Duty Company Email: Service@raelnational.com
Site Contact Email: ryeridge@cava.com
Site Contact Phone: 914-268-9339
SERVICE INFORMATION
Service Type: Time and Materials I Call Type: Problem Type: Repair
ETA: 05/12/2023 12:07 AM ( ETC: 06/30/2023 11:59 PM I Work Order Creation Date: 05/12/2023
Trade(s): Fire Protection
Service(s): Kitchen Suppression Systems- Bi-Annual/Annual Inspection
Task(s):
WORK ORDER DESCRIPTION
Fire Suppression/Semi-Annual Inspection-January/July Hood Suppression/Semi-Annual Inspection
TRIP DESCRIPTION
Fire Suppression/Semi-Annual Inspection-January/July Hood Suppression/Semi-Annual Inspection
■ +1 814-4.38-7235 1750 Plaza Avenue,New Hyde Park,Ny 11040,US ■Service@raelnational.com
......_.............
_......_....i
1/2 WO#157625
STORE SECTION
Yes Comments
Must Return
-- Property manager require coi before nutting[het fire alarm system on test
_Was the Work Satisfactory?
STORE MANAGER/EMPLOYEE ACKNOWLEDGEMENT
I hereby acknowledge that the above services have been performed and STORE STAMP
completed to my satisfaction.
Rina chavez 08/24/23
Name / Date
V �
Signature
81.-43n-?235 1750 Plaza Avenue,New Hyde Park,NY 11040,Us ■Service@raelnational.com
212 WO#157625
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YOUR SERVICy NJ_ SERVICE TECHNICIAN
WJSM RID -----`—T'-`
Po Bo.130 NHLW RO DELIVERY DATE f
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te d www.r se Did com 30 . —
www.ruuallraid com RO�t�^JT K01
8047235874 TRUCKS
SITE SERVICES
BILL TO
JOB LOCATION Liquid Environmental Solutions
Cava Grill.410043 7651 Esters Blvd Ste 200
3 Rye Ridge Plaza Irving,TX 750634034
Port Chester, NY 10573 Chad Terry
Megan Harvey/Jam Santos TEL: (866)694-7327
TEL: (914)268-9339
.00
TERMS: SCH SERVICE: 8:00 am TIME IN: `
RR Pump(On-Call) WINDOW: TIME OUT: ( j
ORDER DESCRIPTION Net 45 Days 10:00 am
ORDERED BY ORDER k
ORDER DATE DATE WANTED PURCHASE ORDER/JOB ORDER x LES 0003626749
05/02/24 05/20/24 275580052
ASSIGNED DISPOSAL SITE MANIFEST NUMBER
KSvc Frequency On-Call
Last Svc Date: 1/10/2024 Next Svc Date:
CH. QTY UNIT TYPE DESCRIPTION
1 RF_PUMPIT Pump Inside Trap
CHARGE TYPE
1 RF ITSN_CH Inside Trap-Service(Non Taxable)
Inflow: [ ]Flowing [ ]Clogged 2. Outflow: [ ]-Flowing [ ]Clogged 3. Condition of Lid: [ ]Good [ ]Poor
.Total Depth of Contents
" 5. Grease Mantle Depth > " 6. Bottom Solids Depth
Consistency: [ ]Liquid ( ]Thick [ ]Solid 8. Inlet Baffle: [ ]Good [ ]Missing/Broken
Outlet Baffle: [ ]Good [ ]Missing/Broken 10. Location of Grease Trap:
io Check List. ( ]inspected Trap [ ]Trap Pumped [ ]Auto Dispenser Operational Gauons of [3io
omments/Recommended Svcs:
Directions:
Work Order Instructions:
Recurring Service Notes: MUST Use Service Channel IVR or App- Check In and check out. 1. Dial 1-516-500-7776, 2. Enter 1
IVR/PIN#Service
3otese the T # 4.Press the pound sign (#) to confirm number or zero (0)to re-enter
Front Door 60 ft. of hose
Project Notes I Drawing I Diagram
BUILDING DEPARTMENT
VILLAGE OF RYE BROOK DEC — I L;.
938 KING STREET RYE BROOK,NY 10573
(914)939-0668
www.ryebrook.org
FIRE INSPECTION / OPERATING PERMIT APPLICATION
FOR OFFICE USE ONLY: N (?,. 3oA-�''N
Fee Paid: $ �� Q Inspection Date & Time:72 eso/aq l CetilC0i/9 404,
FEE SCHEDULE: Re-inspection Date &Time:
Triennial & Private School Annual Inspection: =$450.00
Public Assembly Annual Inspection: <100 People=$525.00 />100 People=$775.00
******************** ** ***********************************************************************************
Application,dated: 1 Z T 1 Z:�> ,is hereby made to the Building Inspector of the Village of Rye Brook NY,requesting
that a Fire Inspection be conducted at the building and premises listed below for the purpose of issuing a Permit to Operate the business,
private school and/or place of public assembly in conformance with the Code of the Village of Rye Brook,the New York State Uniform
Fire Prevention & Building Code, Title 19 NYCRR Part 1201, and all other applicable local, County, State & Federal laws, rules &
regulations,as per detailed statement described below.
1. Address: 3 & 5 Rye Ridge Plaza, Rye Brook, NY10573 SBL: o)7 Zone:
2. Business/Occupancy Name: CAVA NYS Use Class:
3. Property Owner: Win Ridge Realty LLC Address: 24 Rye Ridge Plaza,Suite 200, Rye Brook NY 10573
Phone# 914-701-4005 Cell# email: ahakanoinCcDwinridae.com
5. Business Owner: Cava Mezze Grill LLC Address:14 Ridge Square NW,Suite 500,Washington DC 20016
Phone# 202-400-2920 Cell# email: permits .cava.com
6. Emergency Contact: Jam Santos Address: 14 Ridge Square NW,Suite 5000ashington DC 20016
Phone# Cell# 201-467-9667 email: Jam.santosecava.com
7. Inspection Escort: Jam Santos Title: Area Leader
Phone#: 201-467-9667 Cell#: email: Jam.santosCcDcava.com
8. Provide a brief description outlining the current and/or intended use of the property:
A-2 Restaurant-Fast-Casual Mediterranean Restaurant with both dine in and To go options.
9. List all Hazardous Materials: N/A
10. Occupant Load: Existing: 95 Proposed: 95 Other:
11. Date& Disposition of Previous Fire Inspection: ❑Pass ❑ Fail
s 1220_1
This application must include the notarized signature(s) of the legal owner(s) of
the above mentioned property, in the space provided below. Any application not
bearing the legal property owner's notarized signature(s) shall be deemed null
and void, and will be returned to the applicant.
**********************************************************************************************************
STATE OF NEW YORK )
COUNTY OF WESTCHESTER ) as:
j 11'i ')I NJ T"D5 ,being duly sworn, deposes and states that he/she is the applicant above named,
(print name of individual signing application)
and further states that he/she is the legal owner of the property to which this application pertains, or that he/she is the
for the legal owner and is duly authorized to make and file this application. That all
(indicate architect,business owner,attorney,agent,etc.)
statements contained herein are true to the best of his/her knowledge and belief,and that any work performed or use conducted
at the above captioned property will be in conformance with the details as set forth and contained in this application and in any
accompanying approved plans and specifications,as well as in accordance with the New York State Uniform Fire Prevention
&Building Code,the Code of the Village of Rye Brook and all other applicable laws,ordinances and regulations.
fib' a
Sworn to before me this Z Sworn to before me this
7
day of N d ✓!�I/� C�� , 20 Z-3 day of , 20�3
jNi , Notary Public
Signature of Property 06uxw, Signature of is
WN A- 14MA)'-rN 3A#L c S&&�
Print Name of Property OWMT Print Name of Applicant
Ne;ary
RICHARD A.YARMY 11 State of New Jersey
NOTARY PUBLIC,STATE OF NEW YORK Rosa Y.Ordofiez
Registration No. 01 YA0013323 My Appointment Expires
Qualified in Westchester County April 19.204
Commission Expires September 08,2027 Z 3
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