SHANTE AFGHANS KENNEL PERMIT RENEWAL (K20-000023).PDF
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Maricopa County Animal Care And Control 2500 South 27th Avenue Phoenix, AZ 85009 (602) 506-7387 Tele. (602) 506-2739 Fax KENNEL PERMIT APPLICATION /Renewal Permit # K20- 0000Z3 Kennel Name: ag; LA 0 New N a me:—VICii4EMIIMMIK - MailingA r cr 4 tk Ms. Marilyn',. Domhoff r 6824 W Karen Lee Ln C ity r\taLVMArtl..L-V2, a'-6Z 85382 Home Phone: 6,Z3 97z? 9 Kennel Location: County Supervisorial District Kennel Phone: Z--2 - xi/oZ 9 Please complete and sign this application and return it to the above address with payment in the amount of three hundred fifty dollars ($350.00) within ten (10) days of receipt. Pursuant to Arizona statute and county ordinance, a person must obtain a kennel permit issued by the Board of Supervisors if the person operates a kennel in which there are five or more dogs which are not individually licensed. A.R.S. §11-1009(A). A kennel is defined as "an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions." A.R.S. § 11-1001(8). An appointment will be scheduled for inspection of the kennel premises by an Animal Control Officer upon receipt of this kennel permit application and fee. This kennel application properly executed and a copy of the inspection report will then be forwarded to, and must be approved by, the Maricopa County Board of Supervisors. The kennel permit form will be sent to you after approval and will be valid for one year from the date of the Board's approval. NOTE: Failure to show for a scheduled inspection and/or failure of inspection will warrant a Subsequent Inspection Return fee of $49 for each additional visit. Failure of inspection may result in denial of the kennel permit and require individual licensing of each dog under the provisions of A.R.S. §11-1008. PLEASE ANSWER THE FOLLOWING QUESTIONS AND INITIAL EACH RESPONSE 1. tyl,(J I/We assume complete responsibility for the kennel at the premises for which I/we are making application for a permit and understand that "kennel" means an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions (ARS 11- 1001). 2. Ma I/We certify that I/We have )gs and that the kennel meets the definition in statute. 3. _2041_ I/We certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals) or 13-2910.01 (dog fighting), or similar violations of any other state, county or municipal animal welfare law. (Violations of license and leash laws DO NOT apply). 4. /n1)( I/VVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the premises of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to Date: 02 I r),..e.e. /9 Applicant Signature practice in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is maintained on the premises for each dog. 5. jai I /We certify that I/We are submitting a valid copy of the rabies vaccination certificate for each dog with this application. 6. )144 I/VVe understand that a dog remaining within the kennel is not required to be licensed individually under A.R.S. § 11-1008. I/we also understand that a dog leaving the controlled kennel conditions shall be licensed under A.R.S. § 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this section. 7. 11046_ I/We understand that a person who fails to obtain a kennel permit under A.R.S.§11-1009 is subject to a penalty of twenty-five dollars in addition to the annual fee. 8. _king_ I/VVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after written notification from the county enforcement agent is guilty of a class 2 misdemeanor.. 9. 114tx-The undersigned understand that that the kennel permit does not authorize the operation of any type of business and is solely used for the purpose of licensing multiple dogs. I/We certify that all of the information INVe have provided is true and accurate under penalty of law. Applicant Signature Date: For Official Use Only: Copies of Valid Rabies Vaccination Certificates for each dog attached Copy of Person's Valid Identification Attached Type of Identification submitted BOS Approval Date Term of Permit 2 of 2 Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.gov Receipt Number: R20-042618 SHANTE AFGHANS KENNELS 6824 W KAREN LEE LN PEORIA, AZ 85382 Receipt Date: 01/07/2020 Person ID: P1224832 Phone: 623 4129739 1/7/2020 1:35:59PM Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K20-000023 $350.00 1 Total Fees Due: $350.00 $350.00 Payments: Cash: Check: $350.00 Credit Card: Would you like to share your experience with our service to you? Please visit our website at http://pets.maricopa.gov and click on "I Want To and Contact MCACC" to email your comments for our review. Total Payments Received: Thank You! Change: Balance Due: $350.00 $0.00 $0.00 Animal Information: A7777777 KENNEL PERM - BORN 9/14/1999, SPAYED, UNKNOWN/MIX, TRICOLOR DOG License Information: Tag Number: License Expires: Animal# Vacc Date: Vacc Expires: Please retain this receipt with your pet's records johnsonk WBUSOFF Maricopa County Animal Care & Control 2500 South 27th Avenue Phoenix, AZ 85009 Phone: (602) 506-7387 pets.maricopa.gov KENNEL PERMIT K20-000023 PREMISE INSPECTION Number of Dogs: 9 Name: MARILYN DOMHOFF Kennel Name: SHANTE AFGHANS KENNELS Mailing Address: 6824 W KAREN LEE LN Kennel Address: Same City: PEORIA State: AZ Zip: 85382 City: PERORIA Zip: 85382 County Supervisorial District: 4 Phone: 623-412-9739 Kennel Phone: 623-412-9739 1. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a valid rabies vaccination certificate? YES 2. Is the kennel an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions? YES NOTE: Copies of each rabies vaccination certificate must be attached to the Kennel Permit Premise Inspection form. CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND N/A DAYS GIVEN BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by check upon each return visit.) This is a RENEWAL application There is no history at the address for the kennel. The property has been inspected and there are currently 9 dogs present, accompanied with current rabies certificates; all dogs are confined to the property in a suitable manner. Deputy Enforcement Agent & Badge #: ROMERO #4 Date: 1/14/2020 October 2015 IAGE ii Months X 18 Years U1 SIZE Onder 20 lbs X 20 - 50 lbs Over 50 lbs D 1 Yr 3 Yr Li Other >PECIES 1SEX )og. X ;Male at IFemale )ther INeuter Specify) I . !Animal Control License )ATE VACCINATED 'PRODUCT NAME 18/06/2018 1 PREDOMINANT BREED 'PREDOMINANT RAfghan. Hound. COLORS/MARKINGS : - ;Blue & Cream NAMF Jennifer Veterinarian: Dr. Michele Johnson License No: AZ 4189 RABIES VACCINATION CERTIFICATE NASPHV FORM 51 (Revised 2007) RABIES TAG NUMBER )wner's Name & Address Print Clearly /- 1 MICROCHIP NUMBER .AST FIRST M.I. TELEPHONE )omhdff Marilyn (623)412-9739 iO STREET 1824 W. Karen Lee Lane CITY Peoria STATE AZ !ZIP nm nn 00004_ ,1EXT VACCINATION )UE BY: 18/05/2021 MANUFACTURER (First 3 Letters) Veterinarian's 2ree4eee fimiteddar rAPAE D 1 yr USDA Licensed Vaccine Signature X 3 yr USDA Licensed Vaccine Address Grand Paws Animal Clinic Li 4 yr USDA Licensed Vaccine 11310 W. Bell Rd Suite #103 LI Initial dose Ll Booster dose Surprise, AZ 85378 174704 Vacc. Serial (Lot) No:— RABIES VACCINATION CERTIFICATE ADAPTED NASPHV FORM 51 PRINT - use ballpoint pen or type Owner's Name & Address fee $: ag Tag #: Cert. Serial #: PRINT LAST\ t vo , 1}efni- rFIRST ( y„.... MI TELEPHONE ' 6 1,23 NO. STRE5 . . CITY /V 1/ it; 41-n7 STATE ZIP SPECIES: Dog Y1 Cat U Other U SEX: Male U Female ilk Altered U AGE: Months 9 u SIZE: Under 20 lbs. 20-50 lbs. ,-, Over 50 lbs. U Li 0-. PREDOMINA T BREED: ' Vis! C40,FS: &at= Alr..q.xlk- - Years U NAME: (Specify) DATE VACCINATED: CO ICQ 161 Veterinarian's # 50/7.35 -0 PRODUCER: rams License No. (First 3 Letters) PRODUC ME: Month Day Year VACCINATION EXPIRES: 1 fo Veterinarian's ame (please print) ryi 0,,J1 1 yr. LicNacc.a.1 3 yr. LicNacc. U cbcfiD-0-14-1 A ignature Ad. - Utit-0 -51 S.- Month Day Year Vacc. Serial (Lot) No. VACCINATION RECORD Name U RABIES U LYME DISEASE U CANINE DISTEMPER U CANINE PARAINFLUENZA U CANINE ADENOVIRUS 2 U CANINE PARVOVIRUS U CANINE CORONAVIRUS 1-D CANINE BORDETELLA LEPTOSPIROSIS Li FELINE LEUKEMIA VIRUS U FELINE PANLEUKOPENIA U FELINE RHINOTRACHEITIS U FELINE CALICIVIRUS U FELINE CHLAMYDOPHILA USCAHNON02066 RABIES VACCINATION CERTIFICATE Tag fee $: ADAPTED NASPHV FORM 51 Tag #: Amer's Name & Address PRINT - use ball point pen or type Cert. Serial #: RINT LAST FIRST MI i i 'r /, ( iyikj ,f7 ,, 7-2 TELEPHONE D. , STREET CITY STATE 676.2. 14. 1 A'a r -I''', 1 .41-1-- 2 ' - 0.-- ZIP 5'3 - - -3-5 ' ' -- 3ECIES: )g 0— it 0 her 0 SEX: Male 0 Female O''' Altered 0 AGE: 3 Mo. to 12 Mo. la— 12 Mo. or older 0 SIZE: Under 20 lbs. 0 20 - 50 lbs Over 50 lbs. I PREDOMINANT BREED: A (7, i s COLOR& / / 'NAME: / pecify) NTE VACCINATED: PRODUCER: ?..i.o 33 Veteri / narian's # q — License ,---7 lonth Day Year kCCINATION EXPIRES: .... 6 A 7 t• (First 3 Letters) 1 yr. Lic./Vacc. 0 3 yr. Lic./Vacc. q 15(.3/1. Veterinarian's Signature ,/,,:-...": ' Address t---i- Co 3'15 onth Day Year Vacc. Serial (Lot) No. 0410001 VACCINATION RECORD Name 0 RABIES 0 LYME DISEASE 0 CANINE DISTEMPER 0 CANINE PARAINFLUENZA 0 CANINE ADENOVIRUS 2 DI CANINE PARVOVIRUS CI CANINE CORONAVIRUS 0 CANINE BORDETELLA Li LEPTOSPIROSIS 0 FELINE LEUKEMIA VIRUS 0 FELINE PANLEUKOPENIA 0 FELINE RHINOTRACHEITIS El FELINE CALICIVIRUS I=IFELINE CHLAMYDIA 0 FELINE IMMUNODEFICIENCY VIRUS 1%7\ Boehringer Ingelheim RABIES VACCINATION CERTIFICATE ADAPTED NASPHV FORM 51 PRINT — use ballpoint pen or type Owner's Name & Address Tag fee $: Tag #: Cert. Serial #: PRINT LAST 1 off-3 FIRST MI YOM /1 Ma r i 1-(t yv/ A TELEPHONE 445 --ra- 9 17 ,P2 NO STREET CITY STATE /,,___ Le ZIP SPECIES: Dog V-- Cat D Other D (Specify) SEX: Male Di Female '$---- Altered Di AGE: Months Q SIZE: 20-50 lbs. ii--- Over 50 lbs. Di Under 20 lbs. 'O PREDOMINANT BREED: COL: Years i — NAME: 4r k es- ; DATE VACCINATED: Veterinarian's # PRODUCER: cs 0 License No. (First 3 Letters) PRODUCT NAME: -1 Month Day Year VACCINATION EXPIRES: ' 21 Veterinari as Name (please print) ,._-. ..: (0 --)( A., n 1 yr. LicNacc. D 3 yr. LicNacc.34 --)-=1 (-)n k \----xcrars re.024, \ 3, ,I, ,,,,,in, Signatu wall ‘.....,k )cc_53 1 r it _ A ___ --.)" _S Month Day Year Vacc. Serial (Lot) No. USCAHNON02066 VACCINATION RECORD Name U RABIES ED LYME DISEASE U CANINE DISTEMPER U CANINE PARAINFLUENZA U CANINE ADENOVIRUS 2 U CANINE PARVOVIRUS Di CANINE CORONAVIRUS U CANINE BORDETELLA LEPTOSPIROSIS U FELINE LEUKEMIA VIRUS U FELINE PANLEUKOPENIA U FELINE RHINOTRACHEITIS U FELINE CALICI VIRUS Ur FELINE CHLAMYDOPHILA RABIES VACCINATION CERTIFICATE / Tag fee 5: ADAPTED NASPHV FORM 51 Tag #: PRINT bail type Cert. Serial #: miner's Name & Address - use point pen or RINT LAST ) TO FIRSI, MI Domli fil PIT ligi v ,/,`" TELEPHONE a„.8' - -117-2 - i1.3I° O. STREET 7 / CITY STAT 1419 td ,eb;fren I e-e...— 417 , e 7' ii,..-- . Z.— ZIP , PECIES: og 10— at 0 ther 0 SEX: Male 11. Female 0 Altered 0 AGE: 3 Mo. to 12 Mo. 0 12 Mo. or older Z SIZE: Under 20 lbs. 0 20 - 50 lbs 0 Over 50 lbs.1:7Z PREDOMINANT BREED: 4 19 COLORS: / _NAME: t•-•A C1/4. ;pecify) ATE VACCINATED: 77 — 1 -7 - ' PRODUCER: Veterinarian's # 36 .")) 4-.) i7 0 License No. lonth Day Year ICCINATION EXPIRES: (First 3 Letters) 1 yr. Lic.Nacc. 0 3 yr. Lic.Nacc. Li i 1 3 A Veterinarian's Signature a Address Alffr eA CO 37 Dnth Day Year Vacc. Serial (Lot) No. ‘ VACCINATION RECORD Name C RABIES LYME DISEASE CANINE DISTEMPER fl CANINE PARAINFLUENZA C CANINE ADENOVIRUS 2 CANINE PARVOVIRUS C CANINE CORONAVIRUS C CANINE BORDETELLA LEPTOSPIROSIS CI FELINE LEUKEMIA VIRUS 0 FELINE PANLEUKOPENIA 0 FELINE RHINOTRACHEITIS 0 FELINE CALICIVIRUS 0 FELINE CHLAMYDIA 0 FELINE IMMUNODEFICIENCY VIRUS II III \IMI 11 W Ingelheim 0410001 RABIES VACCINATION CERTIFICATE NASPHV FORM 51 (Revised 2007) Owner's Name & Address Print Clearly 'RABIES TAG NUMBER 1 MICROCHIP NUMBER 1 LAST FIRST M.I. 1 Domhoff Marilyn 1 !!_, • NO STREET CITY STATE 1ZIP 6824W. Karen Lee Lane Peoria AZ 185382 1 TELEPHONE (623)412-9739 :SPECIES !SEX AGE 'SIZE PREDOMINANT BREED 'PREDOMINANT !Dog X !Male ,_ j 1 Months li lUnder 20 lbs []Afghan Hound 1COLORS/MARKINGS1 !Cat ni !Female X 18 Years X 120 - 50 lbs Xl- - 1Blue & Cream I L i 'Over 50 lbs DI NAME ! I ; (Specify) 1 1Joy !Animal Control License r .1 1 Yr ri 3 Yr 0 Other DATE VACCINATED 108/06/2018 'NEXT VACCINATION :DUE BY: 08/05/2021 1 'PRODUCT NAME MANUFACTURER (First 3 Letters) iLi 1 yr USDA Licensed Vaccine IX 3 yr USDA Licensed Vaccine I F-1 4 yr USDA Licensed Vaccine Li Initial dose E1 Booster dose 174704 Vacc. Serial (Lot) No. !Veterinarian: Dr. Michele Johnson !License No: AZ 4189 !Veterinarian's ;Signature 1Address Grancilr a:se:4444i nim:C7f in 11310 W,130 Rd Suite #103 Surprise, AZ 85378 Signed Jessica A. Reed, CX/M DvWI CERTIFICATE OF VACCINATION Date of Rabies Vaccination: 08-15-19 Next Rabies Vaccination On: 08-14-22 VETERINARY CLINIC Sunburst Animal Hospital 5032 W. Thunderbird Road Glendale, AZ 85306 602-938-1860 Certificate No: 0 Previous Rabies Vaccination: OWNER OF ANIMAL Marilyn Domhoff 6824 W. Karen Lee Ln. Peoria, AZ 85382 County: This is to certify... THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW. Patient information... PATIENT: Bo TAG NO: SPECIES: Canine WEIGHT: 63.90 SEX: M AGE: 5 years Color and markings... Fawn/Black Face MICROCHIP: 941000016207260 Rabies Vaccine Information... MFG BY: MERI SER.NO: 18424 LOT EXP: 03/06/21 ADM: SQ License: AZ4051 RABIES VACCINATION CERTIFICATE ADAPTED NASPHV FORM 51 Owner's Na PRINT - use ballpoint pen or type Name & Address Tag fee $: Tag #: Cert. Serial #: PRINT LAST FIRST MI ')Oirlb OiCF (14 a 1r i IIIN NO. STREET CITY STATE TELEPHONE ef2-LA vv K&r-ai, 1,24 1\ P € 0 r:zk pc? SPECIES: SEX: AGE: SIZE: ZIP Dog .15., Cat D Other D (Specify) DATE VACCINATED: Male NS,,, Female U Altered D Months .,R Under 20 lbs. iD 20-50 lbs. D Over 50 lbs. ‘C.1 PREDOMINANT BREED: A c ,, 1- ' " *V COLORS: biLi e b i ?nal t_ Years q- NAME: (V\ ; ,c+ r it ,-.- 1., D — A P\ PRODUCER: B Veterinarian's # --1, '146- License No. o E (First 3 Letters) PRODUCT NAME: „ g-t‘OVAC2 Month Day Year VACCINATION EXPIRES: ,--,........„,_ 1., 0 Month Day Year Veterinarian's Name (please print) - i. V ik 1 yr. LicNacc. '/It 3 yr. LicNacc. D r 0 5:41 c ,i 4 Signature q wer, Address L/ T C C:73- o Vacc. Serial (Lot) No. USCAHN0N02066 VACCINATION RECORD Name D RABIES U LYME DISEASE D CANINE DISTEMPER U CANINE PARAINFLUENZA CANINE ADENOVIRUS 2 CANINE PARVOVIRUS U CANINE CORONAVIRUS U CANINE BORDETELLA LEPTOSPIROSIS FELINE LEUKEMIA VIRUS D FELINE PANLEUKOPENIA D FELINE RHINOTRACHEITIS U FELINE CALICIVIRUS D FELINE CHLAMYDOPHILA c lp)12 ABIES ccINATION CERTIFICATE A PTED NASPHV FORM 51 Owner's Name & Address PRINT - use ballpoint pen or type Tag fee $: Tag #: Cert. Serial #: TELEPHON PRINT LAST , FIRST MI ii ii ii 0611\ t" 0' J' J t f / -,1 6,...---:) ' i NO. STREET t CITY C ATE W. 2' i4..; i',..,.;.I., 1: ..W.' •-r_1,,,./ l'.- :I I ' ...e 1 it • - / SPECIES: Dog a# Cat 0 Other 0 (Specify) SEX: Male 1,7.Y. Female U Altered 0 AGE: / Months if-, D SIZE: X Unr6 lbs. L7.1 0 lbs. D Over 50 lbs. / PREDOMIN BREED: , COLORS: ' 1 At% ,:)C• t Years Q.... 20- e'l NAME: I , r DATE VACCINATED: \F>F0D 1 1- .-? ,) (Zi Month Day CER: Veterinarian's # .1 (1..0 C License No. (First 3 Letters) P' *DUCT NAME: c', r, 3' r— '- VACCINATION EX" S: 1-2- - -- - Mo - Day Year Veterinarian's Name (please print) . 0 r- ns s 1 yr. LicNacc. -titi,, 3 yr. LicNacc. U 3 5:, ,. 1 • 1 (2, p„ Vacc. Serial (Lot) No. Signature 121•11--- 's Address V t:...1- o 1 -'.1 VACCINATION RECORD RABIES O LYME DISEASE CANINE DISTEMPER D CANINE PARAINFLUENZA D CANINE ADENOVIRUS 2 U CANINE PARVOV1RUS U CANINE CORONAVIRUS D CANINE BORDETELLA LEPTOSPIROSIS D FELINE LEUKEMIA VIRUS U FELINE PANLEUKOPEN1A U FELINE RHINOTRACHEITIS U FELINE CALICIVIRUS FELINE CHLAMYDOPHILA Signed Mark A. Stevens, DVM License: AZ1246 Rabies Vaccine Information... MFG BY: ZOE SER.NO: 343374B LOT EXP: 09/22/20 ADM: SQ yfes CERTIFICATE OF VACCINATION Date of Rabies Vaccination: 07-29-19 Next Rabies Vaccination On: 07-28-22 VETERINARY CLINIC Sunburst Animal Hospital 5032 W. Thunderbird Road Glendale, AZ 85306 602-938-1860 Certificate No: 0 Previous Rabies Vaccination: OWNER OF ANIMAL Marilyn Domhoff 6824 W. Karen Lee Ln. Peoria, AZ 85382 County: This is to certify... THAT I HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW. Patient information... PATIENT: Saxon TAG NO: SPECIES: Canine WEIGHT: 46.20 SEX: M AGE: 19 weeks Color and markings... Cream MICROCHIP: 276098106892058