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I <br /> <br />SAMAQUIN <br />—COUNTY-- <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />. To be completed by APPLICANT <br />Business Name Kay's Creation <br />Owner/Operator Name Karen Tabar <br />Business Mailing Address 535 W. Cancion Ct <br /> <br />Lic. Plate # <br /> <br />city Moutain House State Ca Zip 95391 Bus. ph. 510-600-1240 <br />I Karen Tabar hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Sig nature Ka.reiv Tab at Date 5/20/2021 <br />2. To_be coriipleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name POP <br />Address 563 W Clover Rd <br /> <br />FA#0024074 <br />Bus. Phone 209-833-0003 <br />Alt. Ph. <br />city Tracy zip 95376 <br />Check all appropriate services provided: <br />Owner/OperatorAlan and Michelle Lim <br />ra Wastewater disposal <br />Ey Solid waste disposal <br />91 Hot & Cold water for cleaning <br />9' Store dry food/supplies <br />Michelle Lim <br />cti 3-compartment sink <br />Food preparation <br />cr Store refrigerated food <br />0 Overnight parking <br />clri Electrical hook-ups <br />WToilet and handwashing <br />Potable water <br />Vehicle wash <br />hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <br />7114 .C./ba Lan. <br />' 3. To be Completed by the_ENY_ITIEALTITI jurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />RENS Signature <br /> <br />Date <br /> <br />Signature Date 5/21/2021 <br />1868 E. Hazelton Avenue I Stockton, Califomia 952051 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd