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YES <br /> NO <br />Date: XMFF operator's Signature: X <br />7 <br />F:\data\Environmental Health\Food\MFF form\Commissary Application.doc <br />DEPARTMENT OF ENVIRONMEn . <br />3800 Cornucopia Way, Suite C, Modes,. <br />Phone: 209.525.6700 • Fax.., <br />www.stahv <br />M 6^ a7t::mjDul i !□□□□□□□□□ ' <br />ap ^siaiazi <br />□□□ ” <br />Stnring la t* iho Bost <br />I, the above-mentioned MFF owner/operator have answered the questions to the best of my knowledge, and will 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 the commissary is discontinued, I will notify the Stanislaus County Department of <br />Environmental Resources to make the.necessary changes. <br />COMMISSARY AUTHORIZATION <br />FOR COMMISSARIES LOCATED OUTSIDE OF STANISLAUS COUNTY <br />’; Pleasd make sure the writing is as clear as possible..JAndlieglbie ^pliqstion'wjjl result in.^ delator denial of a permit.) <br />IMPORTANT: -’For any mobile food facilities'; bp'efatitjg frofri a "qpmmissary that is located, outride;of this county, the <br />operator must.complete this foigi. t <br />. The mobile food facility must possess the^cappbiljty of hplcjjng. potentially> hazardous foods at the required <br />temperature range during transportation. USing: an. ioe. chesft is not an approved method to hold potentially <br />hazardous foods (except ice.cream and whole-fish) according.to’Caljfprnia Retail Food,Code Section §113885. <br />. The applicant must attach a current Health’PS'rmit of the comhidsarj with this sheet.' ‘ <br />' ; y ______________________________ ________■/ l\ '; ?__------------------------ <br />The following must be completed, and the shaded area must be completed by the local Environmental Health inspection <br />agency for commissaries located outside Stanislaus County: <br />Commissary Name j 0 /J C It H f \ <br />Business Address / 'J / U. K( / 0 H <br />City S c 76 A/ <br />Phona^^z " <br />Inspector's Signature: <br />Will the mobile food facility be stored at the commissary overnight? □ YES eg( NO <br />Does the mobile food facility possess a generator or inverter to supply power to the cold holding unit during transit? <br />c>^j YES I I NO <br />Has the inverter received approval from the California Department of Housing and Community Development? <br />L.L..LX.LX..D <br />County <br />Inspectors Name VC<\<\€c\t\fye \"\C\re5______________________ <br />Phone ZXdCl - <o l>o ~ Job Title Sf <br />Date: X