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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION FORM 2120 DIAMOND BOULEVARD , SUITE 100 , CONCORD , CA 94520 B CONTRA COSTA ( 925 ) 608 - 5500 - ( 925 ) 608 - 5502 FAX http : //cchealth . org/eh / HEALTH S L RV I C E S retailfood@cchealth . org MOBILE FOOD FACILITY ( MFF ) COMMISSARY SERVICES AGREEMENT FORM ❑ CONTRA COSTA COUNTY COMMISSARY OUT- OF - COUNTY COMMISSARY ( Requires Out-Of-County Environmental Health verification ) FOR MULTIPLE COMMISSARIES , SUBMIT A COMPLETED COMMISSARY FORM FOR EACH LOCATION . A . FACILITY • ❑ MFF COMMISSARY RESTAURANT * El PRODUCTION KITCHEN * ❑ OTHER : * Must have an Additional Commissary Permit if in Contra Costa County . B . COMMISSARY INFORMATION Facility Name : PN14) CUM. 12SV41L � Facility Address : . }I omb Facility Phone # : 20cl Cl Fax : M2 Facility Owner Name : J �l E - mail : C . COMMISSARY OWNER/ OPERATOR AGREEMENT I , OWNER/ OPERATOR, WILL PROVIDE THE FOLLOWING SERVICES TO MFF APPLICANT : COMMERCIAL COOKING KITCHEN YES P4NO ❑ OVERNIGHT MFF PARKING /STORAGE YES NO ❑ FOOD/ EQUIPMENT DRY STORAGE YES VNO ❑ LIQUID WASTE DISPOSAL YES i/NO ❑ REFRIGERATED / FROZEN FOOD STORAGE YES [/NO ❑ ELECTRICAL HOOK UP YES �/NO El WAREWASHING AREA YES ;,// NO ElGREASE/ OIL DISPOSAL YES i�' NO ❑ POTABLE WATER SUPPLY YESJ/NO ❑ GARBAGE AND REFUSE DISPOSAL YES 00 ❑ 1, OWNER/OPERATOR, hereby declare that 1 hold a valid environmental health permit to operate as a commissary as defined by the California Retail Food Code, Chapter 10 meeting the California Retail Food Code, Section 114294-114297 and 114326 commissary requirements. 1 will notify Contra Costa County Environmental Health Division by written document, of any change in the status of my operation, my environmental health permit, when this commissary agreement is terminated or when the MFF fails to utilize the services checked above at this commissary. 'cam i 4 Print Commissary Owner/ Operator : lIIU ✓ \� 2 (� Signature : . 0Date : /11 D . MFF OWNER/OPERATOR • ' • 1, MFF OWNER/OPERATOR, 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) (CRFCSec. 1142971. 1 will store the MFF at the approved commissary or another approved location overnight. I will notify Contra Costa County Environmental Health Division in writing of any changes to this agreement. a MFF Business Name : License Plate # : Print Owner/ Operator . Signature : Date : E . OUTmOF = COUNTY COMMISSARY • • • If commissary establishment is outside of Contra Cosa County, the local environmental health jurisdiction shall verify current commissary health permit by signing below . Food establishment is in 8 616,MdV�A County/City . Facility above meets California Retail Food Code , Section 114294- 114297 and 114326 commissary requirements . The ove checked requirements are available at the proposed commissary . REHS Name . tt, LSignature . REHS # : Phone # : 2J)) ' (D m �-NX 0 E - mail : iL Z.t� �`� 11+ x' Date :