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S A N J O A Q U I N Environmental Health Department <br /> _.—..-C O J N T Y--- <br /> Gre;tnr�,s grows hr-re, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 APPLICANT <br /> Business Name Bama Flavor Lic. Plate#4MB7110 <br /> Owner/Operator Name Arthur Allen & Kimberly Absher <br /> Business Mailing Address 5513 Cypress Creek Way <br /> City Salida State CA Zip 95368 Bus. Ph. (209) 750-2542 Alt. Ph.(209) 604-7051 <br /> 1, &jh L>k, Alle h, 4 K(M� Ak;oh,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 4Date <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 /> 0 Wastewater disposal 12 3-compartment sink ® Electrical hook-ups <br /> 0 Solid waste disposal ❑ Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning ❑ Store refrigerated food lJ Potable water <br /> ❑ Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br /> Mark Luis Cruz , hereby state that the information I 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 owner shall notify the EHD immediately. <br /> Signature Date O.,-&1 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the 1 <br /> commissary requirements in California Health & Safety Code. The above checked services are available at th \ <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> kc, V;)-,-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 /> V�0 SIA �v'33� <br />