Laserfiche WebLink
SAN.JOAHI N Environmental Health Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Fl—. To be completed by APPLICANT <br /> pineappleWHIPS,LLC <br /> Business Name _ Lic.Plate# 4RP3463 <br /> Owner/Operator Name Jeffrey Taplin and/or Janeen Goedde-Taplin <br /> Business Mailing Address 4701 Fairfax Avenue <br /> City Oakland State CA Zip 94601 Bus. Ph.(510)698-1981 Alt. Ph.(510)640-2617 <br /> 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. 9/612023 <br /> Signature - Date <br /> 2 To compielit'byCOMMISSARY"OWN,ER/OPERATOR � <br /> Commissary Name_L FA# <br /> Address <br /> 11(*I01LI W rJ 'RQ Bus. Phone 4O`1 <br /> City+-N-IK�-�n _Zip Owner/Operator �' Y <br /> Check all appropriate services provided: <br /> Wastewater disposal 13 3-compartment sink Electrical hook-ups <br /> Solid waste disposal O Food preparation Toilet and handwashing <br /> ® Hot&Cold water for cleaning 0Store refrigerated food P Potable water <br /> ® Store dry food/supplies tH,/Ovemight parking Cif'Vehicle wash <br /> I C 4VYlS� hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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. r� <br /> Signature Date / 2- <br /> 3. To b com leted by the ENV HEALTH jurisdiction=outside,of'San Joa uin Co. <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/ehdAdd <br /> , <br /> janeen@pineappiewhips.com <br /> I <br />