Laserfiche WebLink
ZS�ao3 � <br /> yAN JOAQUIN Environmental Health Department <br /> y ' <br /> COMMISSARY AGREEMENT <br /> ► Mobile Food Facility• Caterer <br /> Complete sections t and 2. It your commissary is located outside of San Joaquin County also complete section 3 <br /> 1. To be comFeted b APPLICANT <br /> Business Name Tortillena Mexico Mi Amor Lic.Plate#4WB5994 <br /> Owner/Operator Name Karen Femanda Equivel Lopez <br /> Business Mailing Address 3712 Popoio Cir <br /> City Stockton State CA Zip 95212 Bus. Ph.(209)426-8020 Alt. Ph. <br /> 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Max's Kitchen LLC FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 OwnerlOperator William Berkowitz <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal E3 3-compartment sink ® Electrical hook-ups <br /> 0 Solid waste disposal ❑ Food preparation 0 Toilet and handwashing <br /> 0 Hot&Cold water for cleaning Q Store refrigerated food M Potable water <br /> 13 Store dry food/supplies EZ Overnight parking 0 Vehicle wash <br /> 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 Califomia Health&Safety Code requirements. It 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. ��yy <br /> Date <br /> Signature <br /> 3. To be cam leted b the ENV HEALTH 'urisdiction outside of San Joa uin Co. <br /> The commissary is located in < l"t's �� _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 change <br /> REHS Signature_D Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 I www.sjg0v.org/ehd <br /> V <br />