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SAN JOAQUIN Environmental Health Department <br /> C D!.. r <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility . Caterer <br /> Complete sections 1 and 2. If your commissary is located outside o1 San Joaquin County also complete section 3. <br /> --- -- <br /> 1 1. To be completed by APPLICANT <br /> Business Name Cousins Maine Lobster Lic. Plate# z 13 7 F 3 <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 /> l 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{y.� r � 4 <br /> Signature �4„�� Date 8/3/21 <br /> be_completed by COMMISSARY OWNER/OPERATOR k i ;u <br /> Commissary Name i �1��11 ( ( ' FA# <br /> Addrecss'- _ �1i X Bus. Phone <br /> City : XJC'S(7jq'fLN1P40 Zip 1 Owner/Operators <br /> Check all appropriate services provided: <br /> `g[ Wastewater disposal 3-compartment sink Electrical hook-ups <br /> `id-Solid waste disposalood preparation ,Toilet and handwashing <br /> Hot & Cold water for cleaning �tstore refrigerated food Notable water <br /> tore dry food/supplies Overnight parking �ehicle wash <br /> I, �!l�� hereby state that the information I have provided is current, true and <br /> correct to best of my knowledwlede and meets the California Health&Safety Code requirements. If the food facility <br /> operator falls to comply with, conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n ti th EHD immediately. — ✓ — <br /> Signature Date l J <br /> 3. To be complete a ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. 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 Date <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 />