Laserfiche WebLink
Environmental Health Department tit <br />COUNTY <br />SAN JOAQUIN <br />99.1514:1, <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 C&A Group LLC <br />Lic. Plate #53652G1 <br />Owner/Operator Name Cesear Davalos <br />Business Mailing Address 1013 Woodrow Ave <br />City Modesto State CA Zip 95350 Bus. Ph. (209) 589-8384 Alt. Ph. <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 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />FA# <br />Address 1211 S. 7th Street <br />City Modesto Zip 95351 <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />V_ Hot & Cold water for cleaning <br />Store dry food/supplies <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 />Date <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in S Jr-61 n (O() S 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 malui Date <br /> <br />(,7 1243 112.ti <br /> <br />1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sigov,orgiehd <br />Pic .2-1-1 002..iI(c <br />Date <br />Bus. Phone 209-338-3663 <br />Owner/Operator William Berkowitz <br />.4 3-compartment sink <br /> <br />• Electrical hook-ups <br />Food preparation <br />3 Toilet and handwashing <br />Store refrigerated food <br /> <br />• Potable water <br />Overnight parking <br />V! Vehicle wash <br />Signature