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S1917 r F <br /> Ly. i <br /> 38ff{3 cornocop's VVH., .t,. 35P-9494 <br /> � ',,77y r ,c-�conty.com <br /> COMMISSARY VERI ICA T lON FOR MOBLE FOOD FAC <br /> Please make sure the writing is as clear as possible. (An illegible application will resin' <br /> MOBILE FOOL?FACIL iTY INFORMATfON <br /> Business Name T r a v e 1 in ' T o to ' s Coffee c Lodi i ices�s� <br /> Vehicle Make C ' h e v Model: v <br /> Type of operation 0 MFF F MFF with Limited Food Preparation phone 2 Q -9- ,w <br /> Permitee's Name S ii e n c e r s T r a v e 1 i n c C <br /> Address 8 3 8 C o b b l e s o Z! e C t - - - <br /> City R i p o n State C A lip 9 5 ` 6 <br /> COMMISSARY INFORMATION <br /> .-usiness Name M a X r S K. 1 t C r e N? _ L L. <br /> Address t2 1 1 S 7 t h S t r e e t <br /> w <br /> city M o d e s t o f <br /> _ State C Fj, Zip 9 _5_ 3 5 1 <br /> Phone 2 0 9- 3 3 g Jw,3 6 6 3 Commissary w`thin Stanislaus County Pi YES [' NO� <br /> AUTHORIZATION (to be completed by Com,lissary owner/authorized representative) <br /> Spencers Travelin Coffee LLC II of Travelin' Toms Coffee of Lodi has permiGsion to use tie above <br /> MFF business operator I MFF business nerve <br /> food establishment as a commissary. TH.e commissary can accommodate the vehicle business:;wnvr with the following <br /> functions (check all that apply): <br /> ❑ Cutting and trimming food [J Cooking food U Rapid cooling of food <br /> B Washing and cleaning food i ❑ Refrigerated food storage ❑ Dry food storage <br /> ❑i Supply food product i 6�1 Supply potable water Ware-washing <br /> pJ Waste water removal j 0 Waste grease removal B Toilet& hand-washno <br /> 0 Overnight parking ❑✓ Electrical hook-up F�d Vehicle cleaning <br /> Wastewater from an MFF must be discharged to L wastewater system through a grease interceptor. <br /> The California Retail Food Code requi ' that mobile food facilities operate from approved commissaries. dlobils food <br /> facilities are to report to the commissary at least once each operating day for cleaning and servicing operatit~'iG i agree <br /> to immediately notify the Stanislaus Cb tnty Department of Environmental Resources if the vehicle busin,3s operator <br /> discontinues the use of this commissary. II <br /> I <br /> Commissa Operators Name (print): Mark Luis Cruz Title (print): F;ng;;kol� A► <br /> Commissary Operator's Signature:X Date:X <br /> I, the above-mentioned MFF owner/oper for have answered the questions to the best of my knowledge, enc 'v�ll operate <br /> out of the above-mentioned commissary and report to the commissary at least once each operating day for cleaning and <br /> servicing (as noted above). If the use of he commissary is discontinued, I will notify the Stanislaus County Department of <br /> Environmental Resources to make the essary ch nges. <br /> D <br /> MFF operator's Signature- X 1 �.,7 <br /> �-- Date:X / <br /> F:Idata\Environmental Health\Food\MFF form\Commissary Application.doc <br />