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<br />SAN JOAQUIN Environmental Health Department <br />I 11 )` 1 <br />C', <br />,) <br />-'- <br /> —COUNTY <br />Greatness arov, he <br /> <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 />To be completed by APPLICANT <br />Business Name i-s 71-1, 1-c-ea3iç Lic. Plate #7 '7 ‘16-f "1'3 <br />Business Mailing Address 616 e-y% r) <br />City -).-A-pt lAk,$)i-cState(1- Zip 'r 3 c/ Bus. Ph. 51 t›- 1 Alt. Ph. <br />6-1)---`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 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Max's Kitchen LLC <br />Owner/Operator Name 6: (-) R I 4: <br />Date ) <br />FA# <br />City Modesto zip 95351 <br />Check all appropriate services provided: <br /> <br />Owner/Operator William Berkowitz <br /> <br />Bus. Phone 209-338-3663 Address 1211 S. 7th Street <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />12 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />Pi Electrical hook-ups <br />Toilet and handwashing <br />Er Potable water <br />El Vehicle wash <br />I, 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 <br /> <br />Date 9 <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in -17-At 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 />Date 171 I 20'14 <br />1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Mic20D361 <br />RENS Signature '-)\ ,*\