ÐÏà¡±á>þÿ :<þÿÿÿ789ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á3 ð¿dFbjbjÔÔ UÞ¶b¶bU;Ñ:ÿÿÿÿÿÿlnnnnžžžTòššš˜24fôòg`f f | | | r%r%r%9f;f;f;f;f;f;f$ni Žkh_fižr%Ô$^2%@r%r%_f)nn| | XÈf)))r%^n†| *R| 9f)r%9f)À)Ú/ƒ^€ô6|"c| Z 0\¸Áó®Èò¨šÐ%²`,c$Þf0g/`Øök}‚&˜slc)òònnnnÙMobile Food Facility Application All Fees must be paid before inspection. Payment alone does not guarAntee the right to operate. For permit costs Refer to current fee schedule. qð ðEnclosed Mobile Food Facility (37)Unpackaged foods, Cutting, Preparing, Cooking FoodsType of Food Safety Exam: ___________________________________________ Date Exam taken: _________________ Certificate Expires: _________________qð ðMobile Food Facility (36)(Circle type of vehicle/cart): Hot dogs, espresso, shaved ice, whole uncut produce, golf snack cart Name of Food Safety Certificate Holder: _________________________________ (Required for Mobile Food Facilities who handle non-prepackaged foods)qð ðIce cream truck (40)Pre-packaged onlyqð ðPlan check review for all non-NSF mobile food facilities and carts. Submit 3 sets of plans qð ðIce cream push carts: qð (1-4 carts) (33) qð (5-10 carts) (34) qð (11 or more) (35)qð ðVeteran / Non-Profit Exempt (39) (Requires copy of DD-214 or proof of Non-profit status) qð ðAuxiliary Conveyance qð ðMobile Support Unit qð ðChange of Commissary only qð ðChange of Ownership Permit Holder s Name as it appears on driver s license (Last Name, First Name)Email AddressPermit Holder s AddressCity/State/ZipPermit Holder’s Telephone (if different)Registered Vehicle Owner’s BusinessTelephonePermit Holder’s Driver’s License # and Expiration DatePermit Holder’s Social Security or Federal Tax ID#Legal Business Name (DBA)Care Of (billing office or person in charge)Billing AddressCity/State/ZipPermit Holder’s FAX#Registered Vehicle Owner’s NameRegistered VehicleYear / Make / ColorVehicle Identification Number (VIN)#License Plate # COMMISSARY* Commissary NameTelephoneCommissary AddressCity/State/Zip I, _____________________________________, agree to allow, ____________________________, the use of my facilities as their commissary, pursuant to California Retail Food Code, Chapter 10. I will notify Contra Costa Environmental Health by written document upon termination of this agreement and/or when the operator no longer uses these facilities in compliance with public health regulations. This commissary agreement is good until ______________________. Date ___________________________________________________________________________________________________________________________________________________________________________________________ SIGNATURE POSITION / TITLE DATE *Complete “Outside of County Commissary Form”, if commissary is located outside of Contra Costa County. The undersigned hereby applies for a Permit to Operate in Contra Costa County and agrees to operate in accordance with all applicable state and local regulations, laws, and such inspection procedures needed to ensure compliance. Payment of the required fee and late penalties, if any, to secure a valid permit is required before commencing or continuing operations. Failure to do so may result in a misdemeanor citation, permit suspension/revocation proceedings, and/or closure. Notify Contra Costa Environmental Health of any change in the type of business activity, name, billing address, or ownership by calling the number above. PERMITS AND FEES ARE NOT TRANSFERABLE. ___________________________________________________________________________________________________________________________________________________________________________________________ SIGNATURE POSITION / TITLE DATE FOR OFFICE USE ONLYFA #PR# P/E: 16 ______XRReceived by:Supervisor:Amount Due: $___________Amount Paid: $____________Check #:___________________ CASH Credit Card: MC___ VISA___Date Received:Mobile Food Facility Supplemental Form The following items must be completed prior to the food vehicle inspection. Complete mobile food facility application. Provide copy of permit holder’s current driver’s license and vehicle registration (if applicable). Produce trucks and pre-packaged, non-potentially hazardous food vehicles must provide copies of receipts where food is purchased. Wholesalers business name, address, phone number must be included. (Produce vehicles are permitted to sell only whole uncut produce) Provide copy of approved restroom agreement if mobile food operation is stationary for more than 1 hour. (Restroom is required to have hot and cold running water, wall mounted soap and paper towels and be accessible during mobile food facility hours of operation. Operators selling non-prepackaged and/or potentially hazardous foods shall provide a written operational procedure for food handling and cleaning and sanitizing of food contact surfaces and utensils. (Mobile food facilities who handle non-prepackaged foods shall obtain an approved food safety certificate) Provide copy of food safety certification or copy of food safety class registration within 60 days. We require re-certification every 5-years. You will not be permitted without one. All applicable fees paid in full. (Payment alone does not guarantee the right to operate!) Operating without a current health permit may be subject to legal action and will incur a penalty of three times the permit fee. Approximate time leaving commissary _______A.M. _______P.M. Approximate time returning to commissary ______A.M. ______P.M. Mechanical refrigeration is present, indicate power requirements below: (Choose one only) Engine 110V Electrical Generator Other Route schedule, copy of route map, location of sales, (include cities and streets): ___________________________________________________________________________________________________________________________________________________________________________________________________. List all foods to be sold (including ice/condiments). Specify any non-prepackaged foods. (Attach additional sheets if needed.) _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ List of food equipment and utensils (including disposable.) _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ Have vehicle inspected after the above items have been submitted to our office. Be sure to schedule an appointment at least 24 hours in advance. ( Any applicant missing an appointment by more than 30 minutes must reschedule. Cancellations must be received by Environmental Health a minimum of 24 hours prior to the appointment or a no show penalty fee will be charged. No shows will be charged at the current hourly rate. You may be subject to a business license and/or peddler’s permit. Business license for unincorporated areas of the County call (925) 646-4230. Peddler’s permit for unincorporated areas of the County call (925) 335-1570. Within City Limits, contact that appropriate City. Contact local city/county agency to obtain a conditional use permit (CUP) if required. All licenses and permits must be valid before Environmental Health Division will issue a permit. Permanent signage on both sides of vehicle. (NO MAGNETIC SIGNS) Business name at least 3 inches high with 3/8 inch stroke lettering, address and phone number at least one inch high in contrasting color. Have all equipment ready to be tested. Food vehicles and carts must have adequate power to operate equipment. Bring your own power source. All food equipment and utensils shall be commercial grade. ( Mobile food facilities are required to obtain Department of Housing and Community Development (HCD) approval. Contact (916) 255-2501 for further information. Outside Of County Commissary Agreement* I hereby declare that I hold a valid environmental health permit to operate a commissary as defined by the California Retail Food Code, Chapter 10. *Include copy of valid environmental health or State permit. Commissary NameCommissary AddressCity, State, ZipTelephoneFAX I hereby declare and certify that ______________________________________, with license plate ________________ is operating out of the above Vehicle Name commissary. This commissary agreement is good until _____________________. Date I understand and agree to provide the following requirements: (Check all that apply.) Vehicle/Cart Storage Food Preparation area Utensil Washing area Liquid waste disposal to: qð ðMop Sink qð ðWash Pad Garbage and rubbish disposed of in a sanitary manner at above commissary. Hot and cold potable water, protected from potential back flow, is available for the unit. Approved restrooms are available for the vehicle/cart operators at the above commissary. Sufficient storage space which is designated for the operator’s mobile food facility. I will notify Contra Costa Environmental Health by written document, of any change in the status of my operation, my environmental health permit, or when this commissary agreement is terminated. Commissary Owner/ManagerDate Print Name ENVIRONMENTAL HEALTH DEPARTMENT: If commissary establishment is outside of Contra Costa County, the local environmental health jurisdiction shall verify current commissary health permit by signing below. Food establishment is in _______________________ County. Facility above meets commissary requirements (California Retail Food Code, section 114294-114297) The above checked requirements are available at the proposed commissary. Signature of County REHSDate Print NamePhone # MOBILE FOOD FACILITY CHECKLIST FAILURE TO COMPLY WITH STRUCTURAL AND OPERATIONAL REQUIREMENTS MAY RESULT IN A RE-INSPECTION FEE AND/OR CLOSURE OF VEHICLE! FOOD PROTECTION Maintain potentially hazardous hot foods at or above 135ºF Maintain potentially hazardous cold foods at or below 41ºF Provide protective plastic covers for all light fixtures Food for customer self-service needs to be pre-packaged Properly label prepackaged foods sold for customer self-service. On the label, include common name, weight, name/address of manufacturer or distributor, ingredients in descending order by weight, and for potentially hazardous foods only include the words “perishable keep refrigerated” FOOD STORAGE Maintain refrigeration unit(s) in good repair Provide approved mechanical refrigeration (food grade) Provide refrigerator doors that are tight-sealing Eliminate rust on racks within refrigerator unit(s) Provide an accurate thermometer in the refrigeration unit Provide an accurate thermometer in the warming oven Provide/maintain an approved probe thermometer that is ±2ºF accurate Provide an accurate thermometer in the customer service chillers Store all hazardous items (i.e., insecticides, cleaners, etc.) separate from food items EMPLOYEE SANITATION Provide soap and paper towels in wall-mounted dispenser at handwashing sink Smoking, consuming food and/or beverages in food preparation areas is prohibited Assure food handlers wear appropriate hair covering and clean clothing Provide and maintain approved sanitizer in vehicle VERMIN Eliminate vermin infestation(s) – i.e., cockroaches, flies, rodents Provide a receipt of pesticide treatment from a licensed pest control company Remove all dead insects/rodents/droppings from all parts of the vehicle Provide self-closing device for entry door; keep door closed Provide/maintain tight-fitting insect screens at service openings that are self-closing and in good repair Provide/maintain in good repair insect screens at all ceiling vents Seal all seams, holes and gaps to prevent vermin entrance/harborage WATER Provide hot (120ºF minimum) and cold running water to sinks at all times Provide quick disconnect for water fill line Provide secured pistol grip nozzle for washdown hose WASTE Eliminate leak(s) in wasteline(s) from sinks and/or coffee urn Connect all wastelines to waste tanks Eliminate leaks from ice compartment Provide waste tanks with proper cap and valve assemblies Maintain cap and valve assemblies to waste tanks closed when outside commissary Provide watertight trash receptacles large enough to accommodate a day’s business Provide/maintain an approved first aid kit Repair/replace damaged and worn cutting boards Dispense self-service customer utensils with mouthparts down, handles-up in proper dispensers Provide a wall-mounted, minimum 10 B-C approved fire extinguisher with a current State Fire Marshall tag, in the vehicle Provide positive closing lids and latches for coffee urns, deep fat fryers, steam tables Maintain all utensils on the vehicle clean and in good repair All equipment must be NSF/ANSI certified; eliminate all unapproved cookware from vehicle (i.e., enamel and/or porcelain-based) FACILITIES Provide/maintain exhaust fans and approved baffle filters in good operating condition Clean exhaust hood and grease filters Clean ceiling vent screens Clean floor Clean walls/ceiling Clean under warming oven; shelf under grill; under steam table Provide an approved alternate, unobstructed means of exit (minimum 2 ft x 3 ft) in the side opposite the main exit door, roof, or the rear of the unit. The exit shall be labeled “Safety Exit”, in contrasting color to the vehicle, with at least 1-inch high letters Repair/replace defective light fixtures and/or bulbs throughout vehicle and provide shatterproof covers MISCELLANEOUS Maintain valid Contra Costa Health Permit in vehicle Maintain City business license in vehicle and conditional use permit Provide business name of vehicle (at least 3-inches high and 3/8-inch brush stroke letters), address and telephone number (at least 1-inch high) of operator or commissary on both sides of the vehicle Provide documentation of approved commissary use Obtain Fire Department approval Provide proof of vehicle certification by the State Department of Housing and Community Development Maintain vehicle registration Provide food safety training certificate Maintain bathroom agreement on vehicle Please see reverse side for important conditions concerning IMMEDIATE vehicle closure. IMMEDIATE CLOSURE OF THE VEHICLE WILL OCCUR IF ANY OF THE FOLLOWING VIOLATIONS ARE OBSERVED: Lack of hot/cold water at sinks Major temperature violations observed in foods and equipment Mechanical refrigeration unit not operating Liquid waste being produced from vehicle and draining onto the ground Lack of sanitizer in vehicle Lack of soap and towels in vehicle for proper handwashing Vehicle is not maintained in a clean and organized manner Presence of vermin Lack of permit CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION 2120 DIAMOND BOULEVARD, SUITE 200 CONCORD, CA 94520 (925) 692-2500 (925) 692-2502 fax www.cocoeh.org FILENAME vehicleapplication.doc(11/99) Revised 10/07 SR# / PR#__________ Mobile Foods SR# / PR#__________ DlnpŽ’¾¾ÀZ\^`†Z\ð~ € ‚ „ † ¢ Ò Ô Ö ø ¢ ¤ ¦ Î Ö Ø 02XZ\’ "$&NVZ†ŠŽÌêàÕÌÃ¹³¹¬¥¬ÌÃ™¹¬¥¬’¬ÌÃ™¹¬ÌÃ¹¬‰ÌÃ¹¬Ã¬Ã¬Ã¬ÌÃ¹¬‰ÌÃ¹¬Ã¹¬Ã¹CJOJQJaJCJOJQJ5CJOJQJ\aJCJOJQJCJOJQJ 5CJ\5CJOJQJ\CJOJQJaJCJOJQJaJ5;CJOJQJ\:CJOJQJ^J)j5;CJOJQJU\mHnHu6Djl’Ê2¾ÀXZ’ÐZ\ööööëëëëëë’LëëëëëX$$If–l4ÖF”ÿh€¼+Ô€€<ö6ÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laö ÆàÀ!$If $ ÆàÀ!a$UE&F`FcFþþþþ\ð~ € ® Ò ` ž ôô›@ôôôôX$$If–l4ÖF”ÿh€¼+Ô€€<ö6ÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laö ÆàÀ!$Ifž ¢ Xž "ø¦››››U´››E$$If–l4Ö0”ÿ€¼+€ì€<ö6ÖÿÿÖÿÿÖÿÿÖÿÿ4Ö laö ÆàÀ!$IfX$$If–l4ÖF”ÿh€¼+€Ô€€<ö6ÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laöÌÐöúüÄÐÑÚîªÔ<=¶ÝÞšÄÅÙÚãäèéòóö’¡¢£÷ëäÙÑÉÂÑä»Ñ°Ñ¦Ÿ»•¦°ÑŽ‚wäräÂjrÂÑräÑr`:CJOJQJ^J5OJQJ\OJQJB*CJOJQJph5B*OJQJ\phÿÿÿCJOJQJ5CJOJQJ\CJOJQJ5CJOJQJ\5CJH*OJQJ\CJOJQJCJOJQJ5CJOJQJCJH*OJQJ5;CJOJQJ\CJOJQJ5CJOJQJ\aJCJOJQJaJ$øúü¢ ¾ À ð 0ÌÃ¸¸HD¸¸¸o$$If–l4Ö”°Ö0”ÿ^Š*Ê,Ö0ÿÿÿÿÿÿöö*öÖÿÿÖÿÿÖÿÿÖÿÿ4Ö laö ÆàÀ!$If $ ÆàÀ!a$2$$If–l4Ö”ÿ¼+€(,ö6ÖÿÖÿÖÿÖÿ4Ö laö01^•È~`sss ÆàÀ!$If$$If–lÖ”°ÖF”ÿ¢ˆŠ*æ Ö0ÿÿÿÿÿÿöö*öÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laöÈÉã{ pp ÆàÀ!$Ifƒ$$If–lÖ”°ÖF”ÿ¢—Š*õ óÖ0ÿÿÿÿÿÿöö*ööÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laö!0EÔ‚‚‚ ÆàÀ!$Ifr$$If–l4Ö”°Ö0”ÿ¢Š*èÖ0ÿÿÿÿÿÿöö*ööÖÿÿÖÿÿÖÿÿÖÿÿ4Ö laöEFfy{Ðpp ÆàÀ!$Ifƒ$$If–lÖ”°ÖF”ÿ¢—Š*õ óÖ0ÿÿÿÿÿÿöö*ööÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laöyzŽ³Ã(‚‚‚ ÆàÀ!$Ifr$$If–l4Ö”°Ö0”ÿ¢Š*èÖ0ÿÿÿÿÿÿöö*ööÖÿÿÖÿÿÖÿÿÖÿÿ4Ö laöÃÄÅÑáë{rrdd $ ÆàÀ!$Ifa$ $ ÆàÀ!a$ƒ$$If–lÖ”°ÖF”ÿæ —Š*R±óÖ0ÿÿÿÿÿÿöö*ööÖÿÿÿÖÿÿÿÖÿÿÿÖÿÿÿ4Ö laöëìÿÚîªÔ<’Œ„„’{nd{{[ $ ÆàÀ!a$ ÆàÀ!„$^„$ $ ÆàÀ!¤¤a$ $ ÆàÀ!a$ $ ÆàÀ!$Ifa$m$$If–lÖ”°Ö0”ÿ¸Š*$ÒÖ0ÿÿÿÿÿÿö6ÖÿÿÖÿÿÖÿÿÖÿÿ4Ö laö <=ÝÞšÄÅÙÚßäóöùððððùâØvvvvv ÆàÀ!$Ifa$$If–lÖÖ”ÿœ*+ Ö Ö ÿÖ0ÿÿÿÿÿÿö6ÖÿÖÿÖÿÖÿ4Ö laö $ ÆàÀ!$Ifa$ $ ÆàÀ!a$ ÆàÀ! 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