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SAN JOAOUIN <br />COUNT" <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Business Name Yogurt Mill Lic. Plate.—JI i- `'` <br />Owner/Operator Name Yogurt Mill Inc. Larry Young <br />Business Mailing Address 4600 Glass Ct Ste A <br />City Modesto State Ca Zip 95356 Bus. Ph. 209 523-2057 Alt. Ph. 209 765-1816 <br />Larry Young , 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 penaltie .. , r <br />Signature !A Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name La Comisaria <br />A(i rlrocc 1211 S 7th St <br />Phone 209 338-3663 <br />Modesto Zip 95351 Owner/Operator <br />Check all appropriate services provided: <br />• Wastewater disposal 3 -compartment sink 0 Electrical hook-ups <br />rd Solid waste disposal ix; Food preparation Q Toilet and handwashing <br />Q Hot & Cold water for cleaning i-4 Store refrigerated food Q Potable water <br />Cl Store dry food/supplies L) Overnight parking 1; Vehicle wash <br />I, /' 5 ru `J i S 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 notitv the EHD immediately. <br />:7-1� &/�Q <br />13. To be completed by(thq ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in _ <br />commissary requirements in Calt <br />above commissary. Please notify <br />REHS <br />1 County. The above food facility meets the <br />3fety Code. The above checked servjces are vailable at the <br />of their operating permit changes. <br />1868 E. Hazelton' vgnue I Stockton, California 15205 1 T P09 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />