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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION (Contra Costa Health Services)

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD, CA 94520
(925) 692-2500 (925) 692-2502 FAX
http://cchealth.org/eh
REV DATE: 7/8/2016
PRODUCTION KITCHEN/APPROVED FACILITY AGREEMENT
1. TO BE COMPLETED BY APPLICANT
Type of Facility: Temporary Food Facility Non-Ag Vendor Caterer Other
Owner Name:
Name of Business:
Owner Address:
City:
State:
ZIP:
Cell Phone:
Alternate Phone:
I, the above-mentioned owner/operator, will operate out of the Production Kitchen/approved facility noted below.
I will notify Contra Costa County Environmental Health, by written document, of any change in the status of my operation
or when the Production Kitchen is contract is terminated.
I hereby state that the above information is current, true and correct to the best of my knowledge and agree to use the
Production Kitchen/approved facility in accordance with the California Health and Safety Code.
This agreement will expire at the end of each permit year and must be submitted annually.
Signature:
Print Name:
Date:
2. TO BE COMPLETED BY COMMISSARY/APPROVED FACILITY OWNER OR OPERATOR
Type of Facility: Production Kitchen Commissary Restaurant Other
Name of Production Kitchen/Approved Facility:
Facility Address:
City:
State:
ZIP:
Owner Name:
Phone:
I agree to provide to the above mentioned applicant the following: (check all that apply)
Hand washing facilities
Food preparation area
Food preparation sink
3-Compartment warewash sink
Refrigeration/Freezer storage
Garbage and refuse disposal
Dry food/equipment storage
Chemical storage
Restroom with hand washing facilities
Potable water
I hereby declare that I hold a valid Environmental Health Permit to operate a Production Kitchen/Approved Facility. (Include
a copy of a valid health permit)
I hereby declare and certify that the business named in section 1 is operating out of the above Production Kitchen/approved
facility.
I will notify Contra Costa County Environmental Health Division by written document of any change in the status of my
operation, my environmental health permit, or when this Production Kitchen/Approved Facility agreement is terminated.
Signature of Production Kitchen Owner/Manager:
Print Name:
Date:
3. OUT OF COUNTY PRODUCTION KITCHEN/APPROVED FACILITY
Food Establishment is permitted in______________________________________________ County.
Enclose a copy of valid Environmental Health (EH) Permit and obtain a signature from an authorized EH inspector from that county.
The above checked (see section 2) requirements are available at the proposed Production Kitchen/approved facility.
Signature:
Print Name:
Phone:
Date:
FOR OFFICE USE ONLY
FA#:
PR#:
PE:
Received By:
Date Received:
REHS:
Date:
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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION (Contra Costa Health Services)

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Completed 9 February 2021

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