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Get CO Affidavit of Commissary - City and County Denver

Denvergov.org/phi Affidavit of Commissary to be completed by proposed vendor Vendor Business/Trade Name Vendor Telephone Number Business Type Check all that apply Mobile Cart Peddler Temporary Caterer/Other Commissary name Commissary telephone number This is a licensed facility and is inspected by the following regulatory agency I print name Last First MI as representative of the above named business offer this affidavit as proof that my food will be prepared in a licensed facility in accordance with the laws governing mobile and temporary food vendors in the City and County of Denver Article III Chapter 23 of the Denver Revised Municipal Code. CITY AND COUNTY OF DENVER DEPARTMENT OF ENVIRONMENTAL HEALTH 200 W* 14 AVE* SUITE 200 DENVER CO 80204-2732 PHONE 720 865-5401 FAX 720 865-5532 www. I acknowledge that I will submit a new affidavit for approval before I resume selling food if I cease to use this facility as my commissary. I understand that failing to return to the commissary as required may result in a summons to court and revocation of my license. I affirm that the above information is correct and true by signing below. Signature of Proposed Mobile/Temporary Food Service Establishment Operator Date Do Not Write Below This Line Inspector Name ID Inspector Signature Approved Denied Approved with Conditions Nancy J* Severson Manager Application to Provide Commissary Services Business/Trade Name of Commissary Business Address County Contact Name Contact Telephone Number as owner/representative of this facility confirm that print vendor name has permission to operate from the above listed commissary. I read understand and affirm my responsibilities under Section 9-107 Commissary in the City and County of Denver Retail Food Establishment Regulations as adopted by the Board of Environmental Health. I will notify the City and County of Denver Department of Environmental Health Public Health Inspections Division if the vendor ceases to use this facility as required* I understand that failing to notify the Department as required or failing to adhere to the rules and regulations that govern commissaries may result in a summons to court and revocation of my license. I acknowledge that I will submit a new affidavit for approval before I resume selling food if I cease to use this facility as my commissary. I understand that failing to return to the commissary as required may result in a summons to court and revocation of my license. I understand that failing to return to the commissary as required may result in a summons to court and revocation of my license. I affirm that the above information is correct and true by signing below. Signature of Proposed Mobile/Temporary Food Service Establishment Operator Date Do Not Write Below This Line Inspector Name ID Inspector Signature Approved Denied Approved with Conditions Nancy J* Severson Manager Application to Provide Commissary Services Business/Trade Name of Commissary Business Address County Contact Name Contact Telephone Number as owner/representative of this facility confirm that print vendor name has permission to operate from the above listed commissary. .

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