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4 is°,�� fi'P,"ui�ia+1 ,'irr�Y �:h, e3>o}aL:S16d9v§ <br />1 <br />Mobile Food Facility Caterer <br />Cornpleze seciiors 7 and 2 Ifyou!rr commissary is located outside of San Joaquin Coimiy also comf�leie sec%iar� 3. <br />To be completed by APPLICANT <br />t;usiness Name_ Ragin Cajun P<ItChen <br />O%Jvner/Operator Name Blake Broussard <br />3usiness f4�lailing Fddress <br />L;jty PAodesto <br />4004 Heritage D <br />Blake Broussard <br />the best of my a now! ei <br />Safety Code, d S n <br />COmmfssar}'i �_ISC� tlf <br />revocation al d n 'lti- <br />Signature <br />rive <br />hereby state t <br />/da gre utilize my approvCoL ti Emvironlnental He t pe h older must no. Ti e <br />337-522-1029 <br />Ljc. Plate -F 45C8983 <br />Ph <br />the above ilrormaron is current, True and correct to <br />ommissary in accordance with California Health & <br />QeparTment (EiHD) requirements. If the use or` the <br />.HQ. Failure to notify this <br />.�/office <br />rmay re <br />su <br />l <br />t in permit <br />Date <br />j 2. To fie complet�l b`>' GC�IVIM(�SARY O�NNER/OPERATOR <br />Comrnissarr Name_ <br />= <br />address 1211S7th St. <br />La Comisaria Modesto <br />j <br />City p 95351 <br />�US. Prone <br />Owner/Operator <br />FAi209-338-3665 <br />Modesto <br />209-338-3663 <br />Check al[ appropriate services provided: <br />X Wastewater disposal � 3 -compartment sink mei Electrical hook-ups <br />Solid waste disposal a Food preparation =xu Toilet and hand��vashina <br />Hot & Cold water for cleaning x; Store refrigerated food : i Potable water <br />XI Store dry food/supplies Xi Overnight parking F Vehicle wash <br />I, Laura Lopez , hereby state that the Inion -nation I have provided is current, true and <br />correct to the best of iy knov✓_ledge, and meets the California Health & Safety Code requirements. If the food facility <br />Operator fails to ori -1y with t conditions of this agreement; or if this agreement is modified or cancelled; the <br />commissary r r ' a y the EHD immediately. <br />Signature Date <br />� 3. To b.e completed by the ENV HEALTH jurisdiction outside of San Joaquin Co <br />The commissary is located in County. The <br />above food facility meets the <br />commissary requirements in California Health &Safety Code. I he above checked. services are available at the <br />above commissary. Please notify B if the status of their operating permit changes. <br />P.EHS Signature <br />Date <br />f <br />