Commissary Agreement InstructionsCommissary Owner/Operator: Complete this form and provide the Mobile Unit a copy of your current health department permit and last health inspection report. Mobile Unit Owner: Submit this form, the Commissary's health department permit, and last health inspection report along with your Mobile Unit Permit Application.Mobile Unit InformationLicense Plate #:Owner Name(Required) First Last PhoneCommissary InformationCommissary Name:Commissary Owner/Manager Name: First Last PhoneEmail Street Address Address Line 2 City ZIP Code Health Department Permit (provide copy) Issued by:Commissary ServicesFrequency of services provided to the Mobile Unit: Daily Weekly Other Services that will be provided (select all that apply): Approved potable water source Wastewater/refuse disposal Cleaning area for Mobile Unit Overnight parking for Mobile Unit Overnight refrigeration Food preparation area Food storage area Utensil washing area Equipment and utensil storage area CertificationI give the Mobile Unit listed above permission to use my establishment. I will provide the Mobile Unit operator with a copy of my establishment's health department permit and last health inspection report.Owner/Manager Signature(Required)Date(Required) MM slash DD slash YYYY Last Updated: April 24, 2025
