HomeMy WebLinkAboutmff-application-part-d-ada
Ronald Browder
Director
COMMISSARY / COMMERCIAL KITCHEN AGREEMENT
Section 1: Pursuant to California Retail Food Code, I will notify Alameda County Environmental Health
upon termination of this agreement or if the operator voluntarily ceases using this facility
Commissary / Commercial Kitchen Owner Name
Street Address City & Zip Code
Cell Phone # Alternate Phone #
I, (Facility Owner / Manager)̀_________________________________________________________________
Agree to provide the following services to (Operator) ___________________________________________
SERVICES PLEASE MARK YES OR NO
Facilities to prepare or package
food
Toilet & handwashing facilities
Waste tank/sewage disposal
Garbage disposal
Potable (drinkable) water supply
Electrical hook-up
Equipment/utensil storage
Warewash facility (i.e. 3
compartment sink)
☐YES/ ☐NO
☐YES/ ☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
Dry food storage
Waste grease removal
Chemical storage
Overnight parking (MFPU)
Enclosed overnight parking (carts)
Refrigeration/frozen food storage
Supply food product – i.e. ice,
meats
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
☐YES /☐NO
Any “NO” answers must be explained below. Additional commissary agreements may be required:
The printed name and signature of the facility owner/operator is required for the department to accept
this document
Print Authorized Signer Name AA Phone
Authorized Signer Signature Date
Section 2: is required for Commissary/Commercial Kitchen facilities located OUTSIDE of Alameda
County or in the City of Berkeley
If the proposed facility is located outside of Alameda County and Berkeley, the local Environmental
Health Department shall verify that the commissary and/or commercial kitchen has a current health
permit by signing below. The establishment is in ______________________________________ County/City.
An REHS signatures verifies that the facility indicated in Section 1 meets CALCODE: Section 114294 –
114297.
Out of County REHS Name
(Please Print)
Phone
Out of County REHS Signature
And date received
E-mail address
1131 Harbor Bay Parkway, Alameda, CA 94502 | Health.AlamedaCountyCA.gov/ACEHD | (510) 567-6700