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AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br />Arthur Allen & Kimberly Absher of Bama Flavor <br />MFF business operator <br />food establishment as a commissary. <br />functions (check all that apply): <br />Cutting and trimming food <br />Washing and cleaning food <br />Supply food product <br />Waste water removal <br />Overnight parking <br />has permission to use the above <br />MFF business name <br />The commissary can accommodate the vehicle business owner with the following <br />El Cooking food <br />El Refrigerated food storage <br />2 Supply potable water <br />Waste grease removal <br />Electrical hook-up <br />E] Rapid cooling of food <br />Dry food storage <br />Ware-washing <br />Toilet & hand-washing <br />2 Vehicle cleaning <br />DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3800 Cornucopia Way, Suite C, Modesto, CA 95358-9494 <br />Phone: 209.525.6700 • Fax: 209.525.6774 <br />www. stancou nty. com <br />COMMISSARY VERIFICATION FOR MOBILE FOOD FACILITIES <br />Please make sure the writing is as clear as possible. (An illegible application will result in a delay or denial of a permit.) <br />MOBILE FOOD FACILITY INFORMATION <br />Business Name B a m a F 1 a V 0 <br /> <br />License # 4 M B 7 1 1 0 <br />Vehicle Make WLCRG <br />Model V A N <br />Year 2 0 0 2 <br />Type of operation [1 MFF 111 MFF with Limited Food Preparation Phone 2 0 9 - 7 5 0 - 2 5 4 2 <br />Permitee's Name <br />Arthur Al 1 en &IC imb er 1 y Ab s her <br />Address <br />5 5 1 3 <br />Cypress Creek Way <br />City Salida State C A <br /> <br />Zip 9 5 3 6 8 <br />COMMISSARY INFORMATION <br />Business Name Max S <br /> <br />Kitchen LLC <br /> <br />Address <br /> <br />1211 S . <br /> <br />7th Street <br /> <br />City Modesto <br />Phone 2 0 9-3 3 8-3 6 6 <br />State C A Zip 9 5 3 5 1 <br />3 Commissary within Stanislaus County pi YES 0 NO <br />* Wastewater from an MFF must be discharged to a wastewater system through a grease interceptor. <br />The California Retail Food Code requires that mobile food facilities operate from approved commissaries. Mobile food <br />facilities are to report to the commissary at least once each operating day for cleaning and servicing operations. I agree <br />to immediately notify the Stanislaus County Department of Environmental Resources if the vehicle business operator <br />discontinues the use of this commissary. <br />Commissary Operator's Name (print): Mapc Luis Cruz <br />Commissary Operator's Signature: X <br /> <br />Title (print): Bookkeeper <br />Date: X 15 Y-0/-2 'y <br /> <br />I, the above-mentioned MFF owner/operator have answered the questions to the best of my knowledge, and will operate <br />out of the above-mentioned commissary and report to the commissary at least once each operating day for cleaning and <br />servicing (as noted above). If the use of the commissary is discontinued, I will notify the Stanislaus County Department of <br />Environmental Resources to make the necessary changes. <br />MFF operator's Signature: X Date: X <br />P05' 14,33 I F:\data\Environmental Health\Food\MFF form\Commissary Application.doc