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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E Hazelton Ave, CA 95205 •:• Phone(209)468-4320 •:• Fax(209)464-0138 e}www.sigov.org/ehd COMMISSARY AGREEMENT Mobile Food Facility 0 Caterer Please complete Sections 1 and 2. If your commissary is outside of San Joaquin County please also complete Section 3. Section 1 -To be completed by APPLICANT—Please print or type. Business Name A " 4;�kOo+ T4- C41er-;i?i PR# Owner/Operator Name JoCe�( n Cyoa-smK'n Business Mailing Address S'SS ma '( 9=A w S?a c0 31 Suite City Y-000�eGa State Zip OjS33 10 Home Phone 209-g 14'1'Mg Bus. Phone I, , )OCe%'Jn ( S"-W" , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with the California Health&Safety Code, and San Joaquin County Environmental Health Department, requirements. If the use of the commissary is discontinued, the permit holder must notify this office to the necessary changes. Failure to notify this office may result in permit revocation and penalties. Signature � Date Section 2-To be completed by COMMISSARY OWNER/OPERATOR—Please print or type. n Commissary Name IplD A,(YDW C>Y) PR# Address \ kA) _ t JT 1�2.�� Bus. Phone 2bR-(o59- 3286 City Xfa\ .\I Zip 915 20 b Owner/Operator ri l,nIr-C\%rl Check all appropriate services provided: .K-Wastewater disposal .t7 Food preparation area ErRefrigeration equipment otable water lectrical hookups 2rFood storage facilities Disposal of rubbish&garbage ATToilet&handwashing facilities ❑Janitorial sink ❑ Hot&cold water for vehicle cleaning .2 s-compartment sink ❑ Overnight vehicle storage ❑ Other services not listed: List all foods provided by the commissary and company(ies)from which foods are purchased: � � pP !Food Company k2olt IWC. �'cort'-'riC5, on•oan /Y, S 1cIe4c3 claSilYr f/an5 �'Jt2a-� bb NN GndwjG� KI G r1 GS I V LS I, L Y' 1 hereby state that the information I have provided is current, true and correct to the bet of my knowledge nd meets the California Health &Safety Code requirements. If the food facility operator fails to comply with the nditions of this c tact, or if this contract is modified or cancelled, the commissary owner shall notify this office immediately. \� _ Signature n Print Name � nvi ��(nh7A h Date Z w Section 3-To be completed by the ENVIRONMENTAL HEALTH jurisdiction outside of San Joaquin County The commissary is located in County. The above food facility meets the commissary requirements pursuant to CalCode Sections 114211, 114245.1, 114294 and 114326. The above checked services are available at the above commissary. Please notify the Sonoma County Department of Health, Environmental Health&Safety should the status of this permit change or if it falls below acceptable CalCode standards. EHS Signature Print Name Date Business Phone: Commissary Agreement(in and out of county) Rev.05/16