Laserfiche WebLink
2,�_w3Q� <br /> Mark Lawlckl,R,E.H.s, Fran <br /> R�Yrpsd Emev.+wnr lMsA s <br /> Ermiim RulR•souroa Environmental Health Department <br /> sdoo QMV01110 Vft suer c <br /> MedMCAMi 01 r) <br /> &W M <br /> .rwwRwrrrso�ero.eorrr +SARY AGREEMENT <br /> WE BUILD COMMUNITY Food Facility o Caterer i <br /> C,'m y W aedktns f 8"d 2. N your CWM98sory fa Rated Aufskle of Son Jorrrtuin County also cnmprefe section 3 <br /> t.To be cam leted <br /> BusinessNomeGna'a Tacos Lic,Plate#4VP1952 <br /> Ownerloperator Name GuiAermina Valazquez <br /> Business Mailing Address 404 S Central Ave <br /> eq.Lodi State CA Zip95240 Bus, Ph.(209)735-0784 it.Ph, <br /> t. hereby state that the above Information is current,true and cared to <br /> ft best of my knowledge and agree to utilize my approved commissary in accordance with California Health 3 <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 END. Failure to notify this office may result in ipenInd <br /> revocation and penalties. <br /> Signature Date <br /> be completed by COMMISSARY 4WNERIOPERATOR <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S.71h Street Bus.Phone 209-338-3663 <br /> City Modesto zip 95351 Otivner/Operator William Berkowitz <br /> Check all appropriate services provided- <br /> 0 Wastewater disposal E3 3-compartment sink 0 Electrical hook-ups <br /> 0 Solid waste disposal Cl Food preparation 0 Toilet and handwashing <br /> 0 Hot&Cold water for cleaning ® Store refrigerated food El Potable water <br /> Q Store dry food/supplies d Overnight parking 0 Vehicle wash <br /> 1. Mark.�.uis cm hereby state that the information 1 have provided is current true and <br /> corre-:t to the[vest of my l noWedge,and meets the California Health&Safety Code requirements. If the fool facility <br /> «C+eratof fails to ornFly with the conditions of this agreement.or if this agreement is modified or cancelled, the <br /> cemit ssary o vnei shall f4 the EHD immediately, <br /> Signature Date 't 257 <br /> t coin let d .th®ENV EALT jurlseiichvn outside of Sara ( aa uin Co, <br /> The commissary is located in AzS-)4'j County.. The Above Tool facility meets the <br /> commismary requue+r�r3ntx In CeMtornla Health 8 safety Coda. The above checked services are available at the <br /> above commissary, Please notify FH If the status of their operating permit changes. <br /> REH9 Signature _ Z A- L�J "fed , ���= Date 3• .� 0 s?Q <br /> 1868E lia,irlionAvemlO t StCckion,California 952051 T 209 468.34201 F 209 464.0138 1 wow stgov.orgiehd <br /> i <br />