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SAN JOAQUIN Environmental Health Department <br /> r <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility . Caterer , <br /> Complete sections 1 and 2. I(your commissary is located outside of San Joaquin County also complete section 3. <br /> L1_To be completed by APPLICANT , r,�.-4M�:*�7" <br /> Business Name Cousins Maine Lobster Lic.Plate# -1137 F3 <br /> Owner/Operator Name Operator-Erin Mutscheller <br /> Business Mailing Address 1947 N. Cahuenga Blvd. Suite 108 <br /> City Los Angeles State CA Zip 90068 Bus. Ph. 619-459-2185 Alt. Ph. <br /> 1• , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <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 EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature � � Date 8/3/21 <br /> 2 To be completed b f-COMMISSARY OWNER/OPERATOR <br /> Commissary Name l� L1 �� 11f I lrw FA# <br /> Address�w `� �L 4�O y r k� + `I" l Bus. Phone _ <br /> City ; " (lam Zip ('j ( 1 Owner/Operator' iLS4N <br /> Check all appropriate services provided: <br /> Wastewater disposal -(1b. 3-compartment sink Electrical hook-ups <br /> Solid waste disposalfFood preparation Toilet and handwashing <br /> of&Cold water for cleaning j Store refrigerated food Notable water <br /> tore dry foodlsupplies 'Overnight parking Vehicle wash <br /> I, , hereby slate that the information I have provided is current, true and <br /> correct to best of my knowled ,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply w' conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n ti th EHD immediately. <br /> SignatureDate <br /> 3. To be completed a ENV HEALTH 'urisdiction outside of San Joa uin Co.' <br /> The commissary is located inCounty. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature cQ'-(l.'L'CS v _Date ?^( —1 ( <br /> fie tA- t4Qhs S'ac Ca,.r.5l <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />