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c 4 <br />P <br />2 ,( <br />Greatness grows herr <br />Environmental Health Department SANJOAQUIN <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 />To be completed by APPLICANT <br />Business Name Las Tapatias <br />Owner/Operator Name Elizabeth Mendez Hernandez <br />Business Mailing Address 5550 East Jahant Rd <br />City Galt State CA zip 95632 Bus. Ph. (209 689-4660 <br />Lic. Plate #4GN9940 <br /> <br />Alt. Ph. <br /> <br />I, 'El ),AJAAJJ2 -1_ , 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 />Sig nature \i L\-c\\\ i..q \--‘1-\ Goi‘cL\-\.- <br />To be completed by COMMISSARY OWNER/OPERATOR <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 />Eli 3-compartment sink <br /> <br />121 Electrical hook-ups <br />Solid waste disposal <br /> o Food preparation <br /> 0 Toilet and handwashing <br />0 Hot & Cold water for cleaning O Store refrigerated food <br /> El Potable water <br />lj Store dry food/supplies <br /> <br />0 Overnight parking <br /> <br />0 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 ow s all notify the EHD immediately. <br />Signature Date 0 5 -34 2A1 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 1 to...3->- 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 /> 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 />\'R091 sic <br />Date c),I".;(:, <br />FA# <br />RENS Signature