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SAN JOAQUIN <br />COUN <br />Environmental Health Department <br />RECEIVED <br />APR 08 2024 <br />COMMISSARY AGREEMENT ENVIRONMENTAL HEALTH <br />Mobile Food Facility Caterer PERMIT/SERVICES <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 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 Zi p 95368 <br />the best best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />I, ilirth w- )4-1/e hi 4 Kiitibeati Alwr,L.0 hereby state that the above information is current, true and correct to <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 enalties. i <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address1211 S. 7th Street <br />Bus. Phone 209-338-3663 <br />Bus. Ph. (209) 750-2542 Alt. Ph. (209) 604-7050 <br />i <br />1-6/•— '1"."/' Date 3-- <br />FA# <br />City Modesto <br /> <br />Zip 95351 <br /> <br />Owner/Operator William Berkowitz <br /> <br />Check all appropriate services provided: <br />Wastewater disposal <br /> <br />IW 3-compartment sink <br /> <br />Ewel Electrical hook-ups <br />Solid waste disposal <br /> <br />O Food preparation <br /> 0 Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food <br /> <br />El Potable water <br />Store dry food/supplies C6 Overnight parking <br /> <br />0 Vehicle wash <br />, 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 <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />ounty. The above food facility meets the <br />commissary requirements in California Health & Safety Code. bove checked services are available at the <br />above commissary. Please notify EHD .f the sf. tus of their operating permit changes. <br />( <br />REHS Signature <br /> <br />Date <br /> <br />1868 E. Hazelton Avenue , California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />I , Mark Luis Cruz <br />The commissary is located in coo <br />71OCLIkp3:31