Laserfiche WebLink
�''����``� • SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> S Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 v�T,abecorn letedb APPLLCAN� <br /> Business Name Lupita's Cocktails Lic. Plate#4HU9171 <br /> Owner/Operator NameAbel Nemecio Martin <br /> Business Mailing Address 2844 S Monroe St <br /> City Stockton State CA Zip 95206 Bus. Ph. (209) 484-8470 Alt. Ph. <br /> Abel Nemecio Martin 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, .hlle2l� '14 h Date <br /> 2 'F6$ew'com'" feted % CO,Mi01$%R*Y-, U1/NER%ORERAT <br /> Commissary Name La Comisaria Modesto FA#N/A <br /> Address-1 211 S. 7th Street Bus. Phone(209) 338-3663 <br /> City Modesto Zip95351 Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> M Wastewater disposal ® 3-compartment sink ® Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> ® Hot & Cold water for cleaning ® Store refrigerated food ® Potable water <br /> ® Store dry food/supplies ® Overnight parking ® Vehicle wash <br /> 1, Mark Luis Cruz , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner""shall notify the EHD immediately. <br /> Signature / Sf! Date-.11 n- <br /> 3.,Tobe com letedib ;the:ENV�HtEALT/H� _i �isdiction:outsideWafS:an�Joa '"ulnjCo <br /> The commissary is located in ��r)(,5 1aV6 (!Wn I V 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 EHDA if the status of their operating permit changes. <br /> REHS Signatures I `�I InvGx �v. Date t I Z[ 2Z2;Z- <br /> 1868E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />