HomeMy WebLinkAbout20260219_PJA26-0115_Commissary Agreement � COUNTM44�*iN
HEALTH DEPARTMENT Commissary Agreement
❑ 1 own both the business requiring and the business providing commissary services.
✓ 50 This agreement between the commissary owner and the vendor signifies that both parties agree to the vendors
access to and use of the services identified below. The Snohomish County Health Department will not recognize any
transfer of this agreement to food service facilities or persons not specifically identified in this agreement
Food Service E#abtishment requiring commissary support to qualify for a permit to operate
Name of Establishment: ✓
Owner of
Establishment: l�
Mailing address: -:j' -flq r ill
Phone numbers): LA L- - _ -L .
Email address: ,ri-; Z-u-IA
Business bays&hours:
The following services will be provided by the commissary:
Approved water supply(if yes,attach [Ayes
water/sewerformto application)
❑ No Handwashing sink No Yes ❑
Approved wastewater disposal(if yes,
Yes ❑ No Food preparation sink for vegetables 9 Yes ❑No
attach water/sewer form to application)
Garbage disposal 0 Yes ❑ No Food preparation sink for raw meats in Yes ❑No
Dry storage for food and single service �0 Yes ❑ No Approved 3-compartment sink ®Yes ❑ No
Refrigeration space cubic feet 'Z Yes ❑ No Approved restroom JZ1 Yes ❑No
Freezer space,f,0cubic feet M Yes ❑ No Entrance key for after-hours access 0 Yes ❑ No
Ice in pounds per day lbs. ❑Yes '9 No Power Supply P Yes ❑ No
Fryer Oil Disposal ❑Yes R No
Commissary sewage system 1p Waterfsewer form attached
Commissary water system -0 Water/sewer form attached
Is this commissary connected to a
` ,Yes ❑No
septic system?
Is a grease trap required by sewer 94 Yes ❑ No
district or building department?
Environmental Health Division 1.16.24n
3020 Rucker Avenue,Suite 104 0 Everett, WA 98201-3900 ■fox:425.339.5254 ■ tel:425.339.5250
# SNOHOMISH
CO U NTY 444k Commissary Agreement
*!D HEALTH DE6KENT
I verify the information provided in this agreement is accurate and we are responsible to comply with the Washington
State Food Code(WAC24&215) and will allow access for inspection during business hours for either business
Commissary name: e'
Commissary address: fd
Business hours, -
Commissary owners name: ' H
Commissary phone:
J
Printed Name of cz ni rebury Owner SfQnatvre of Corrurttasary Owner
Dab
�'�Lvv& &L" . '�" -5 1 1 �
Printed Name of Food Sarvks Eat MMmerd o vnar Sig of Food Servke Exubfthmew owner Date
FOR MOBILE FOOD UNITS
Washington State Retail Food Code Requirement(WAC 246-215-09126.4):The PERSON IN CHARGE shall
document presence at the COMMISSARY on a log, maintain records for one year, and shall make the records available
for inspection by the REGULATORY AUTHORITY upon request
Please read through the following statements and Initial to indicate your agreement:
I,the mobile food unit operator, acknowledge that I will be required to maintain logs detailing when I
visit my commissary, how often,and for how long.
I,the mobile food unit operator,acknowledge that I will maintain the logs for a minimum of 1 year.
—f I,the mobile food unit operator,acknowledge that the commissary logs may only be filled out and
stored ON-BOARD the mobile food unit.
Environmental Health Division 1.16 24h
3020 Rucker Avenue, Suite 104 0 Everett, WA 98201-3900 0 fox 425.339.5254■tel:425.339.5250