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SAN ,i0AQUIN <br /> <br />Environmental Health Department <br />C 0 LJ N T <br />6reotness grows here, <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 />1. To be completed by APPLICANT <br />Business Name Bella Habachi <br />Owner/Operator Name C ki ( L.5 CO yoono <br />Business Mailing Address 3 3 / 1 ,5 011 U o f6 re Ln, „si ocloor) <br />City ,5-/ or, le I-0 0 state I A zip V? 12 Bus. Ph. ,_(?() c.0,3) 9 •-,.)-C7?Alt. Ph. <br />I, (/7i'occi yr , . , 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 / 26-(„0-2-, 0,7 Date 05/ /6/ Z 6/ y d <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 />Wastewater disposal <br /> <br />G;C 3-compartment sink <br /> 13 Electrical hook-ups <br />Solid waste disposal <br /> <br />II Food preparation <br /> 0 Toilet and handwashing <br />0 Hot & Cold water for cleaning O Store refrigerated food <br /> <br />Ei Potable water <br />Store dry food/supplies Li Overnight parking <br /> EI Vehicle wash <br />I, 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 <br /> <br />Date <br /> <br />- <br /> <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 />REHS Signature Date <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 />Lic. Plate # 0.3 €2017..3 <br />2. To be complete by COMMISSARY OWNER/OPERATOR <br />FA# <br />K2k-tonci-•