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SNOHOMISH <br /> HEALTH DISTRICT <br /> _,-..--11-6:-.-.8- WWW.SNOHD.ORG <br /> Commissary Agreement <br /> ❑I own both the business requiring and the business providing commissary services and as such no commissary <br /> agreement is necessary. <br /> This agreement between the commissary owner and the vendor signifies that both parties agree to the vendor's access <br /> to and use of the services identified below. Snohomish Health District(SHD)will not recognize any transfer of this <br /> agreement to food service facilities or persons not specifically identified in this agreement <br /> Food Service Establishment(FSE) requiring commissary support to qualify for a Permit to Operate <br /> Name of FSE— — -- '-:. — <br /> Vendor(FSE owner) V, i1, ) .°,1 3 ()--131_00.4 <br /> Mailing address 10' 5 M ; ` ,rte - t®Dv S <br /> Phone number(s) 92_x` 3tb-qq <br /> Business days & hours \4 W W 61pm 64k, 5 1 AM--- 17:bill <br /> The following services will be provided by the commissary: <br /> Approved water supply PlYes ❑ No Handwashing sink VI Yes ❑ No <br /> A roved waste water disposal / Yes Ir <br /> pp p � ❑ No Food preparation sink for vegetables El c, No <br /> Garbage disposal ❑Yes to Food preparation sink for raw meats ❑Yes gNo <br /> Dry storage for food and single service ❑Yes XNo Approved 3-compartment sink jil Yes ❑ No <br /> Refrigeration space cubic feet /Yes ❑ No Approved restroom 4 Yes ❑ No <br /> Freezer space cubic feet ❑Yes ' No Entrance key for after-hours access L_Yes *No <br /> Ice in pounds per day lbs. ❑Yes 'gNo <br /> I verify the information provided in this agreement is accurate and we are responsible to comply with the Washington <br /> State Food Code (WAC246-215) and will allow access for inspection during business hours for either business. <br /> Commissary name 00 ,(t <br /> Commissary address < < ` = :- `-L <br /> Business hours ,M PitiV <br /> -Commissary owner's name M�, tf <br /> Commissary phone �..\---• —341 — y i <br /> ... Signature.of Commissary Owner :.' <br /> .%...P-. ;:.:'.':L,ga. <br /> ;.Printed name of Commissary Owner . ; Date.: . ;. . .. <br /> :-{3. (. :0-.1-A.-'':.:.-*.'..:': <br /> es <br /> A a9 ,WA t <br /> �� � # <br /> Pnnted.name of Food Se ce Es islimen Owner `S1gna. =tiui►•dSarvi. sfa•i merit Owner... .. atel: 1 <br /> CommissaryAgreement EH 06 2094 kkc <br /> Environmental Health Division <br /> 3020 Rucker Avenue, Suite 104 ■ Everett, WA 98201-3900 ■ fax: 425.339.5254 ■ tel: 425.339.5250 <br />