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SAN-J OAQ U I N Environmental Health Department <br /> COUNTY—- <br /> .'f <br /> Ut -.titlY hCre. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 1 and Z if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com leted b APPLICAI T = <br /> Business Name <br /> pineappleWHIPS,LLC Lic.Plate# 4RP3463 <br /> Owner/Operator Name Jeffrey Taplin and/or Janeen Goedde-Taplin <br /> Business Mailing Address 4701 Fairfax Avenue <br /> City <br /> Oakland State CA Zip 94601 Bus. Ph. Alt. Ph.(510)698-1981 (510)640-2617 <br /> I Janeen Goedde-Taplin 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 penalties. 9/6/2023 <br /> Signature Date <br /> 2. Tobe com I b C 5-MM SSS RY OWNER/OPE-RATOR= <br /> Commissary Name L FA# 0027 <br /> Address, -I(D .2 a i}l aq r�) A__Bus. Phone eZO� - 71,Z� [te <br /> City L+r44 bcdp _Zip Owner/Operator 54-AY- <br /> Check all appropriate services provided: <br /> Wastewater disposal D 3-compartment sink Eg/sectrical hook-ups <br /> l(Solid waste disposal O Food preparation 0 Toilet and handwashing <br /> ® Hot&Cold water for cleaning 3 Store refrigerated food P(PPotable water <br /> D Store dry food/supplies !8 Overnight parking Mf'Vehicle wash <br /> y <br /> hereb state that the information 1 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 own hall no e EHD immediately. <br /> Signature <br /> Date <br /> completed-btheEMV H-4tTH urisdlct!or'duts/id6,o!fSZa- <br /> n,Joa uin ico. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> janeen@pineapplewhips.com <br /> �,N1A>E <br />