Laserfiche WebLink
p. <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />CUUN Y <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 />71. To be completed by APPLICANT <br />Business Name Isabela's Mexican Food <br />Owner/Operator Name Ana Isabel Leal <br />Business Mailing Address 4445 W Durham Ferry Rd <br /> <br />Lic. Plate # -t- <br /> <br />C ity Tracy <br /> <br />State CA Zip 95377 Bus. Ph. (209 ) 938-8555 Alt. Ph. <br /> <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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br />City Modesto Zip95351 Owner/Operator William Berkowitz <br />Check all appropriate services provided: <br />FA# <br />gl Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />I. Mark Luis Cruz <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Fa Electrical hook-ups <br />0 Toilet and handwashing <br />Ei Potable water <br />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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd