Laserfiche WebLink
_h PI1205`4 gqj5 <br /> " SH ) O A Q U I N Environmental Health Departms n, <br /> C o U N TV---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLIC`Affi <br /> Business Name Tacos Jessy Lic. Plate#6M2721 1 <br /> Owner/Operator Name_ Ulises Maaana <br /> Business Mailing Address 2247 Melissa Way <br /> City Tracy State CA Zip 95377 Bus. Ph. (415)378-5043 Alt. Ph. <br /> 1, , 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. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator William Berkowitz <br /> Check all appropriate services provided: <br /> V Wastewater disposal V 3-compartment sink W Electrical hook-ups <br /> , Solid waste disposal Food preparation _W Toilet and handwashing <br /> V Hot & Cold water for cleaning Store refrigerated food Potable water _ <br /> 1- Store dry food/supplies Overnight parking Vehicle wash l/,7,� �t-• <br /> Mark Luis Cruz S ppt�d" w��r Sse.►.,-� �fetr/ Aou� OuiG�'h�X <br /> 1, , heteby state that the information I have pt`ov ed i current, true and 1A4 <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 notify the EHD immediately. <br /> Signature 2' Date X3-/3-Z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in ;, : , f 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 /> Al <br /> REHS Signature ! % �- �'1� 8� �'/ Date 6 €Oi— <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />