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♦��.® SAN MATEO COUNTY HEALTH Environmental Health Services <br /> ice:► I Food Program <br /> ■ r• ENVIRONMENTAL 2000 Alameda de las Pull Suite#100 <br /> ®S®�� San Mateo,CA 94403 <br /> HEALTH SERVICES <br /> PHONE(650)372-6200 1 FAX(650)627-8244 <br /> smchealth.org/food <br /> COMMISSARY AGREEMENT FORM <br /> r SAN MATEO COUNTY COMMISSARY ►-OUT-OF-COUNTY COMMISSARY* <br /> *REQUIRES OUT-OF-COUNTY ENVIRONMENTAL HEAL <br /> FOR MULTIPLE COMMISSARIES,SUBMIT A COMPLETED COMMISSARY FORM FOR EACH LOCATION.TM VERIFCA770N BELOW <br /> COMMISSARY NAME: LA- CDjmf.-&`AL COrp OPERATOR NAME: (9,f1 CA;o Al-x+lll <br /> COMMISSARY ADDRESS: Z`fOO E 61VD,rr* were CITY/ZIP: Sli lrSbrJ fSzer <br /> COMMISSARY PHONE#: 210 �(j'{_ ,f 5- COMMISSARY FAX#: <br /> COMMISSARY <br /> C�1ioal-Ate ,9 `0174p 0pM <br /> F_ RESTAURANT COMMERCIAL KITCHEN VEHICLE COMMISSARY r OTHER <br /> I, COMMISSARY OWNER/OPERATOR, WILL PROVIDE THE FOLLOWING SERVICES TO THE MFF APPLICANT: <br /> FOOD PREPARATION AREA r YES fR NO COOKING FACILITIES r YES r NO <br /> REFRIGERATED/FROZEN FOOD STORAGE I- YES I% NO FOOD.& EQUIPMENT DRY STORAGE r YES(- NO <br /> WAREWASHING AREA YES r NOPOTABLE WATER SUPPLY IZ YES r NO <br /> LIQUID WASTE DISPOSAL [t YES r NO GREASE/OIL DISPOSAL 9 YES r NO <br /> GARBAGE DISPOSAL COOKING FACILITIES I- YES NO ELECTRICAL HOOK UP FT YES r NO <br /> OVERNIGHT MFF STORAGE ryLYES r NO ENCLOSED OVERNIGHT PARKING (CARTS)? YES r NO <br /> I, COMMISSARY OWNER/OPERATOR, hereby declare that I hold a valid Environmental Health Services permit to operate a commissary as <br /> defined by the California Retail Food Code, Chapter 10. 'Note: Include copy of valid Health Permit for Out of County Commissaries. I will <br /> notify San Mateo County Environmental Health Services in writing of any change in the stag of my,operation, health permit,or upon <br /> termination of this agreement. <br /> Print Owner/Representative`6 fixV/ 2-.7-- Signature:-', h_� pad <br /> !MFF OWNER/OPERATOR INFORMATION <br /> I, MFF, OWNER/OPERATOR,will operate out of the above-mentioned commissary and report to the commissary at least once each <br /> operating day for Cleaning and servicing(as noted above) [CRFC Sec. 114297). 1 will store at the MFF at the approved commissary or <br /> another approved location overnight(not at residence). I will notify San Mateo County Environmental Health Services in writing of any <br /> changes to this agreement.n <br />—MFF BUSINESS Ni 2D (2o rS LI NSE TE#: 3(16 6 6 7-? <br /> Tint Owner/Representative: 1?Dli R.W1/90eq Signature: Date: 7 �Z <br /> • • ' • • <br /> he proposed commissary is outside of San Mateo County,the local environmental health jurisdiction shall verify the commissary health <br /> rmit is valid by signing below. County/City verifies the above-mentioned commissary meets the requirements <br /> the California Retail Food Code,Section 114294-114297 and 114326. The above checked requirements are available at the commissary. <br /> i•. <br /> HS Name: Signature: REHs# <br /> : '�1,��,�� <br /> one#: A CY—� LI E-Mail: S V Q�Date: -71I? <br /> 011312020 �T" raga 2 of 3 <br />