Laserfiche WebLink
SAN JOAQUIN <br />COUNTY <br />Greorns grows IL- <br />Environmental HealtHmitnt <br />MAR 1 9 2024 <br />COMMISSARY AGREEMENT ENVIRONMENTAL HEALTH <br />Mobile Food Facility Caterer <br /> DEPARTMENT <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Business Name La Toxica <br />Owner/Operator Name Juan Minjares <br />Business Mailing Address 2709 Parkdale Dr <br /> <br />Lic. Plate #91629R3 <br /> <br />City Modesto State CA Zip 95358 Bus. Ph. (209) 771-7471 Alt. Ph. <br /> , 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 />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address 1211 S. 7th Street <br />City Modesto zip 95351 <br /> <br />Bus. Phone (209) 338-3663 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Check all appropriate services provided: <br /> <br />FA# <br />Wastewater disposal <br />La Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />/4arif s C <br />3-compartment sink <br />1-.3 Food preparation <br />El Store refrigerated food <br />15 Overnight parking <br />, hereby state that the information <br />63 Electrical hook-ups <br />Et Toilet and handwashing <br />EI Potable water <br />Er Vehicle wash <br />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_9wjner shall notify the EHD immediately. <br />Signature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in S-e 01,15 iczAs 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 K (4 ( C2-7-o Date (1 I2_02.cf <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Date z9pfiz,( <br />P-ZO 5 Gm oa,0