Fillable COMMISSARY or MSU VERIFICATION (Sacramento County, California)

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COMMISSARY or MSU VERIFICATION (Sacramento County, California)

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Environmental Management
Department
Marie Woodin, Director
11080 White Rock Road, Ste. 200 • Rancho Cordova, California 95670 • fax (916) 875-8513
Env
ironmental Compliance (916) 875-8550 ● Environmental Health (916) 875-8440
www.saccounty.net • emd.saccounty.net
COMMISSARY or MSU VERIFICATION
MOBILE FOOD FACILITY (MFF)/ MULTI EVENT VENDORS (MEV)/ CATERER
MFF/MEV/CATERER BUSINESS INFORMATION:
Type of Facility:
MEV
MFF – Cat. A
MFF – Cat. B
MFF –Cat. C
MFF- Cat. D
CATERER
(Food prep. at commissary)
MFF/MEV/Caterer Business Name:
License Plate Number (if applicable):
Owner Name:
Owner Mailing Address:
City:
Zip Code:
Phone Number: (Work)
Mobile:
I, the above-mentioned MFF/MEV/Caterer Owner will operate out of the below
mentioned commissary and report to the
commissary at least once each operating day for cleaning and servicing (As noted below) (Calcode Sec. 114297). I will store the
vehicle (if applicable) 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.
Signature of MFF/MEV/Caterer Owner
Date
COMMISSARY INFORMATION
:
Type of Facility:
Commissary
MSU
Restaurant
Market
Other
Commissary Business Name:
Commissary Owner’s Name:
Commissary Address:
City:
Zip Code:
Commissary Contact Phone:
MFF Access Hours:
Y / N
Preparation or packaging of food
Y / N
Sewage disposal
Y / N
Overnight parking
Y / N
Toilet & handwashing
Y / N
Potable water supply ( hot cold )
Y / N
Warewashing
Y / N
Electrical hook-up
Y / N
Refrigerated/ frozen food storage
Y / N
Garbage
Y / N
Supplies storage
Y / N
Cleaning Areas drained to wastewater/sewer system
Y / N
Dry food storage
Y / N
Supply food products
I, the Commissary Owner/Representative, can and will provide the necessary facilities as checked for the above-
mentioned
MFF/MEV/Caterer at my permitted facility:
Signature of Commissary Owner/Representative
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:
Comments:
FA #
PR#
2
MFF MENU AND FOOD PREPARATION QUESTIONNAIRE
(Required to be completed for all new permit or renewal of permit applicants)
Menu Items:
Cooking equipment used on the truck:
Cooking equipment used at the commissary:
Where are the food items prepared/cooked:
Where are the food ingredients/supplies stored:
Comments:
Signature of MFF Owner
Date
Inspector Signature
Date
W:\Da
ta\EH-PROGRAMS & PROJECTS\MFF AND TFF WORKING FOLDERS\MFFs\MFF FORMS & HANDOUTS (UPDATED)\WORD DOCS\OPERATOR - COMMISSARY VERIFICATION 12 21 18.doc
Environmental Management
Department
Marie Woodin, Director
11080 White Rock Road, Ste. 200 • Rancho Cordova, California 95670 • fax (916) 875-8513
Environmental Compliance (916) 875-8550 ● Environmental Health (916) 875-8440
www.saccounty.net • emd.saccounty.net
OUT OF COUNTY COMMISSARY
Name of MFF:
Name of Commissary:
Commissary Address:
If the proposed facility is located outside of Sacramento County, 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 signature verifies that the facility indicated in above meets CALCODE Section 114294-114297.
Out of County REHS Name (Please Print)
REHS number
Out of County REHS Signature
Date
Phone Number
Email Address
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COMMISSARY or MSU VERIFICATION (Sacramento County, California)

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Completed 15 June 2021

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