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Get San Mateo Commissary Form

M. P. M. Approximate time returning to commissary P. M. ENVIRONMENTAL HEALTH DEPARTMENT OUT OF COUNTY ONLY If commissary establishment is outside of San Mateo County the local environmental health jurisdiction shall verify current commissary health permit by signing this form. Food Establishment is in County. I will also notify San Mateo County Environmental Health by written document of any change in the status of my operation my environmental health permit or when this commissary agreement is terminated. Signature Commissary Representative Print Name Commissary Representative I the above-mentioned MFF owner/operator will operate out of the above mentioned commissary and report to the commissary at least once each operating day for cleaning and servicing as noted above C. Smchealth. org phone 650 372-6200 fax 650 627-8244 INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED COMMISSARY AGREEMENT FORM SAN MATEO COUNTY COMMISSARY OUT OF COUNTY COMMISSARY REQUIRES OUT OF COUNTY HEALTH DEPARTMENT SIGNATURE BELOW FOR MULTIPLE COMMISSARIES DUPLICATE THIS FORM AND SUBMIT ADDITIONAL COMMISSARY INFORMATION. COMMISSARY INFORMATION CITY/STATE/ZIP COMMISSARY PHONE NUMBER FAX NUMBER I hereby declare and certify that with license plate Mobile Food Facility above commissary. San Mateo County Health Department Environmental Health Services Division 2000 Alameda de las Pulgas Suite 100 San Mateo CA 94403 www. This commissary agreement is valid until. License Plate Number is operating out of the Date I understand and agree to provide the following requirements Check all that apply OVERNIGHT MFF STORAGE GARBAGE RUBBISH DISPOSAL FOOD PREPARATION AREA UTENSIL WAREWASHING AREA HOT COLD POTABLE WATER APPROVED RESTROOMS LIQUID WASTE DISPOSAL FOOD UTENSIL STORAGE COOKING FACILITIES Retail Food Code Chapter 10. Note Include copy of valid Environmental Health or State Permit for out all Out of County Commissary. H. S*C. Sec* 114297. I will store the MFF at the approved commissary or another approved location* If the use of the commissary is discontinued I will notify the Environmental Health Division at 650 372-6200 to make the necessary changes. Signature Mobile Food Facility Operator Approximate time leaving commissary Print Name Mobile Food Facility Operator A. The facility above meets California Retail Food Code Section 114294-114297 and 114326 commissary requirements. The above checked requirements are available at the proposed commissary. Print Name Signature REHS REHS Number Phone Number Email Address. This commissary agreement is valid until. License Plate Number is operating out of the Date I understand and agree to provide the following requirements Check all that apply OVERNIGHT MFF STORAGE GARBAGE RUBBISH DISPOSAL FOOD PREPARATION AREA UTENSIL WAREWASHING AREA HOT COLD POTABLE WATER APPROVED RESTROOMS LIQUID WASTE DISPOSAL FOOD UTENSIL STORAGE COOKING FACILITIES Retail Food Code Chapter 10. Note Include copy of valid Environmental Health or State Permit for out all Out of County Commissary.

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