Sacramento County Moblie Food Facility Permit Application - Commissary Verification

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Sacramento County Moblie Food Facility Permit Application - Commissary Verification Powered By Docstoc
					                                                                                                                                                          FA#____________
                                                                           County of Sacramento                                                           PR#____________
                                             Environmental Management Department, Environmental Health Division
                                    10590 Armstrong Avenue  Mather, CA 95655, Ph: (916) 875-8440  Fax: (916) 875-8513
                                                                                                                                                          CT#____________
                                                                                                 www.emd.saccounty.net
                                                                       COMMISSARY or MSU VERIFICATION
                                                                MOBILE FOOD FACILITY (MFF)/ Multi Event Vendors (MEV)
                              MFF BUSINESS INFORMATION
                              When the mobile food facility is in-service, how do you operate? (check all that apply)
Your Business Information




                              □ Drive a Route - Please list major stops on the back of this form.
                              □ Operate in one location (provide address): _____________________________________________________________________
                              NOTE: Additional local jurisdiction approval may be required for the MFF operating locations.
                                                          MEV          MFF – Cat. A                      MFF – Cat. B                MFF –Cat. C                       MFF- Cat. D
                              Type of Facility:                     (Food prep. at commissary)

                              MFF Business Name (Name on vehicle or cart):
                              License Plate Number:
                              Owner Name:
                              Owner Mailing Address:                                                                  City:                                       Zip Code:
Your Commissary information




                              Phone Number: (Home)                         (    )                                                            (Mobile)        (     )

                               COMMISSARY INFORMATION

                              Type of Facility:                    Commissary               MSU               Restaurant                Market                     Other
                              Commissary Business Name:
                              Commissary Owner’s Name:
                              Commissary Address:                                                                    City:                                       Zip Code:
                               Phone Number: (Business)                        (     )                                (Mobile)           (      )

                               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 below) [C.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 (916)875-8440 to make the necessary changes.
                              [ ] Preparation or packaging of food                            [ ] Potable water supply                         [ ] Overnight parking
                              [ ] Electrical hook-up                                          [ ] Warewashing                                  [ ] Refrigerated/ frozen food storage
                              [ ] Toilet & handwashing                                        [ ] Dry food storage                             [ ] Supplies storage
                              [ ] Waste tank/ sewage disposal facilities                      [ ] Waste grease removal                         [ ] Supply food products



                                                                                          Signature of MFF Owner                                                          Date

                                  I, the Commissary Owner/Operator, can and will provide the necessary facilities as checked for the above-mentioned MFF
                              at my permitted facility:


                                                                                         Signature of Commissary Owner                                                    Date
                                                       NOTE: The signature of Commissary Owner must be a wet/original within 30 days of applying for permit. NO COPIES.

                               NOTE: Use of an unapproved facility for any of above purposes can lead to revocation of your permit to operate.
                               Commissary Approval:               □ Pending         □ Approved       □ Disapproved
                               Verified by: ______________________                  Date_______________           Reason: _________________________________
How is the Refrigeration currently being powered on the mobile unit when it is in-service, away from the commissary?
(i.e. generator, inverter, etc,.)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

List Major Stops:

   Stop #         Time IN         Time OUT          City                                Name and address of each stop/ Major X-streets


        1

        2

        3

        4

        5

        6

        7

        8

        9

       10


*If you are going to park your MFF at one location for longer than one hour, you must complete the Restroom Verification Form.




W:\Data\EH-PROGRAMS & PROJECTS\MFF AND TFF WORKING FOLDERS\MFFs\Updated MFF Forms and Cabs\WORD DOCS\commissary verification updated 01 25 12.doc

				
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