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of ApplicantSignal <br /> CFO (Class A or B) MEHKO <br />Zip: 3^6 <br />Signature of Approval, REHS <br />Date:Sr. Staff Initials:. <br />FAO <br />Zip: 7JTZA5 <br />) <br />O Rental Kitchen <br />Overnight parking <br />Garbage disposal <br />21 Grease/oil disposal <br />0^ Waste tank/sewage disposal <br />0<y <br />Email Address <br />FOR OFFICE USE ONLY____________________ <br />Commissary/Approved Facility Within Santa Clara County: <br />Dist Staff Initials:Emp #Date:-------- <br />PRO <br />Electrical hook-up <br />Potable (drinkable) water supply <br />Ef Supply food product (i.e. ice, meats) <br />0”Chemical storage <br />I /r /zfe <br />Date <br />t <br />Signature of Commissary/Facility, Owner/OperalOr^^^^JJ^e <br />[J Vending Machines Q TFF <br />cofA License Plate: <br />State: ct\ <br />Mobile: ( <br />OUT-OF-COUNTY COMMISSARY/APPROVED FACILITY _ <br />If the proposed commissary/approved facility is outside of Santa Clara County, the local environmental health jurisdiction shall verify that <br />the above-mentioned establishment has a valid health permit, and the above checked services are available to the to the applicant. The <br />facility is located in County/City. <br /> <br />Print Name <br />COMMISSARY AGREEMENT/APPROVED FACILITY 11- Z-^l <br />Mobile Food Facility (MFF), Compact Mobile Food Operation (CMFO), Temporary <br />Food Facility (TFF), Mobile Support Unit (MSU) & Vending Machines <br />This form is to be submitted with proposals for a Vehicle, Trailer, Cart, or Temporary Food Facility. Any foods sold or given away to the <br />public must be prepared and stored in an approved facility. <br />APPLICANT INFORMATION_____________________________________________________ <br />Type of Facility: | 1 Occupied Truck/Trailer Q Unoccupied Truck/Trailer/Cart | | MSU <br />Owner Name: jc^ ,/U-________Name of Business: <br />Owner Address:^^^ __________________City: _____________ <br />Email Address: cc^ . egTelephone: M o -J /f J <br />Provide dates/days of the week and times of commissary use: <br />Where will you be operating? (list address/market/event)______________________________ <br />COMMISSARY/APPROVAED FACILITY INFORMATION <br />Type of Facility: Commissary Restaurant <br />Name of Commissary/Approved Facility: \ t r / ✓ . <br />Facility Address: Cltv: State: v/\ <br />Email Address:Telephone: Mobile: ( ) <br />I, the commissary/approved facility owner/operator, can and will provide the necessary services, as indicated by the applicant, at my <br />permitted food facility. I acknowledge that I am ultimatejyresponsible for the maintenance and sanitation of this commissary/approved <br />facility. In addition, I will notify DEH when this agreement is ferp7fnoted <br /> <br />Print Name xj <br />I, the above -mentioned owner/operator will operate out of the commissary noted below. The facility noted will be providing the <br />following services to my food operations (Check all that apply): <br />0^Facilities to prepare/package food <br />Food storage (dry or refrigeration) <br />0 Equipment/utensil storage <br />0"Warewash facilities (3 compartment sink) <br />For MFF/CMFO/MSU: / will report to the facility at least once each operating day for cleaning and servicing. I will store the vehicle and <br />equipment at the commissary or another DEH approved location by completing the MFF Storage Agreement. <br />If the use of the commissary is discontinued, I will notify DEH at DEHMFF@Geh.sccgov.org to make necessary changes. <br />I understand the use of an unapproved facility for any of the operations above may lead to the revocation of my permit to operate. <br />A/^i/a OD -------- <br />PrintTlame Sienatdo^ of Applicant Date <br /> Emp # <br /> Primary Secondary <br />SANTA CLARA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH (DEH) • CONSUMER PROTECTION DIVISION <br />1555 Berger Drive, Suite 300 • San Jose, CA 95112, MFF Line (408) 918-1908 • Main Line: (408)918-3400 • Email: dehmff@deh.sccgov.org • vAV^.eh|nfo.orgfco£„