Laserfiche WebLink
PARTD <br />^rZ3 125Authorized Signer Signature Date <br />ALAMEDA COUNTY REHS SIGNATURE ONLY <br />Out of County REHS Name (Please Print) Phone <br />Out of County REHS Signature Date Email: <br />REHS PLEASE EMAILTHIS FORM TO : ^ 7 T ~ T J AND 7 7 r- T 7 7 ■ - <br />o:\operationstechnical\food program\unit 5\vehicles\forms\mffapplications\mff application 04 08 24.docx <br />Dry food storage <br />Waste grease removal <br />Chemical storage <br />Overnight parking <br />Enclosed overnight parking (carts) <br />Refrigeration/frozen food storage <br />Supply food product - i.e. ice, meats <br />Alameda County <br />Department of <br />Environmental Health <br />Section 2: is required for Commissary/Commerdal Kitchen facilities located OUTSIDE of Alameda County or in the City of <br />________________________________________ _____ Berkeley <br />If the proposed facility is located outside of Alameda County and Berkeley, the local Environmental Health Department <br />shall verify that the commissary and/or commercial kitchen has a current health permit by signing below. The <br />establishment is in County/City. <br />An REHS signature verifies that the facility indicated in Section 1 meets CALCODE: Section 114294-114297. <br />Q^es Ono <br />Q^es NO <br />Myts no <br />TOES NO <br />TOes O no <br />Dyes no <br />0yes O no <br />E^sOno <br />TOes Ono <br />EprEsONO <br />WES QNO <br />EZJmo <br />)£s Ono <br />fES ono <br />es Ono <br />Commissary/Commercial Kitchen Owner Name <br />PCSIgCNFTIPADO <br />Commissary/Commercial Kitchen City & Zip Code <br />STCCCTW 1^520^ <br />__I___ __ * ~ <br />COMMISSARY/COMMERCIAL KITCHEN AGREEMENT__________ <br />Section 1: Pursuant to California Retail Food Code, I will notify Alameda County Department of <br />_________Environmental Health with any changes to this agreement. <br />Commissary/Commerdal Kitchen Name <br />UNWNCMTONG TE-UOc c CA/TTIZ <br />Commissary/Commercial Kitchen Street Address 5 7 A j,, <br />nil S UNION <7r ST7)cK-TDA/^ <br />r Commissary/Commercial Kitchen Phone Number and Cell Phone Number <br />it - 5 91 !<> _________ <br />I, the Commissary/Commercial Kitchen Authorized Signer (print name) j ^61^A <br />Agree to provide the following services to (print business name) 'f' V <br />PLEASE CHECK YES OR NO: <br />Facilities to prepare or package food <br />Toilet & handwashing facilities <br />Waste tank/sewage disposal <br />Garbage disposal <br />Potable (drinkable) water supply <br />Electrical hook-up <br />Equipment/utensil storage <br />Ware wash facility (i.e. 3 compartment sink) <br />Any "NO" answers must be explained belowAND may delay issuance of the permit. Additional Commissary agreements may be required: <br />