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Food Booth Name: CO'.’ 1 VML I Date Received^! PR#: (5) FOR OFFICE USE ONLY Received By: Date: FA#:_ REHS: :e machine or cooling equipment Potable water □^Garbage and refuse disposal □KDry food/equipment storage Chemical storage □Restroom with hand washing facilities REV DATE: 1/10/2020 CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION 2120 DIAMOND BOULEVARD, SUITE 100 CONCORD, CA 94520 (925) 608-5500 (925) 608-5502 fax EMAIL: cocoeh@cchealth.org WEBSITE: http://cchealth.org/eh CONTRA_jCOSTA HEALTH SERVICES 'PE: COMMERCIAL/PRODUCTION KITCHEN AGREEMENT FOR TEMPORARY FOOD EVENT VENDORS 1. TO BE COMPLETED BY FOOD BOOTH OPERATOR Owner Name: Mailing Address (Oily, State, : 2,^ 3 < Telephone^ 20^^____________________________ pEmallpiV|^s i I hereby declare that the above information is current, true and correct to the best of my knowledge and agree to use the Commercial/Production Kitchen in accordance with the California Health and Safety Code. —(M/ - o d/I Signature:1 Print Name: /M 1 Date: 2. TO BE COMPLE FACILITY CURRENTLY PERMITTED BY HEALTH DEPARTMENT: Commercial/Production Kitchen Name: Facility Address (City, State, Zip): $ $ $ & Owner Name:^),^ i phone(9 W P 7 > I will provide the above-named food booth operator access to the following (if available): □'^Hand washing facilities Food preparation area Food preparation sink □^-Compartment warewash sink Refrigeration/Freezer storage Cooking equipment and ventilation hood __________ Print Name: /'M 1 ________ D BY COMMERCIAL/PRODUCTION KITCHEN OWNER OR OPERATOR p^YES | |NQ vCev CA Email: /OC If Commercial/Production Kitchen holds a valid Environmental Health Permit to operate, include a copy of a valid health permit. I certify that the business named in Section 1 is operating out of the above Commercial/Production Kitchen. . . Qwner/Manaaer SianatureX^t Print Name: VJt X' Date: j // V '*2^— 3. OUT OF COUNTY PRODUCTION KITCHEN (SIGNED BY AGENCY WITH JURISDICTION) ~ The above listed Commercial/Production Kitchen is permitted in County. The above checked (see section 2) requirements are available at the proposed Production Kitchen/approved facility. Include a copy of valid Environmental Health (EH) Permit and obtain a signature from an authorized EH inspector from that County. REHS Signature: Print Name: AC(' $ / o Qt{X Date: / ( 21/1 / Telephone: 6?/ Email: