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Commissary Name C YGNUS HOME SERVICE LL C 5 7 5 INDUSTRIAL PARK DRIVE Business Address City State c A Zip 9 5 3 3 7 M ANT ECA 2 0 9 - 8 2 4 - 3 0 1 1 SAN J OAQU I N Phone County .2 0 7 - - 3 Vs 2. Job Title ‘,167,0,— Phone Inspector's Signature: Signature: X Date: X 8/7 /1? YES LIINO Will the mobile food facility be stored at the commissary overnight? Please make sure the writing is as clear as possible. (An illegible application will result in a delay or denial of a permit.) IMPORTANT: For any mobile food facilities operating from a commissary that is located outside of this county, the operator must complete this form. The mobile food facility must possess the capability of holding potentially hazardous foods at the required temperature range during transportation. Using an ice chest is not an approved method to hold potentially hazardous foods (except ice cream and whole fish) according to California Retail Food Code Section §113885. The applicant must attach a current Health Permit of the commissary with this sheet. The following must be completed, and the shaded area must be completed by the local Environmental Health inspection agency for commissaries located outside Stan islaus County: Inspector's Name o a Does the mobile food facility possess a generator or inverter to supply power to the cold holding unit during transit? YES LIINO Has the inverter received approval from the California Department of Housing and Community Development? YES LIINO DEPARTMENT OF ENVIRONMENTAL RESOURCES 3800 Cornucopia Way, Suite C, Modesto, CA 95358-9492 Phone: 209.525.6700 • Fax: 209.525.6774 www.stancounty.com COMMISSARY AUTHORIZATION FOR COMMISSARIES LOCATED OUTSIDE OF STANISLAUS COUNTY I, the above-mentioned MFF owner/operator have answered the questions to the best of my knowledge, and will operate out of the above-mentioned commissary and report to the commissary at least once each operating day for cleaning and servicing (As noted above). If the use of the commissary is discontinued, I will notify the Stanislaus County Department of Environmental Resources to make the necessary changes. MFF operator's Signature: X 9.42.45e:ve4,& Division Controller Date: X 8/2/2019 F:\data\Environmental Health\Food\MFF form \Commissary Application.doc