Environmental Health “Promoting healthy lifestyles, preventing disease, and protecting the health of our community” Office: (409) 832-4000 ∙ Fax: (409) 832-4270 ∙ 3040 College St ∙ Beaumont, Texas 77701 ∙ kenneth.coleman@beaumonttexas.gov AFFIDAVIT Central Preparation Facility (CPF)/Commissary for Mobile Food Unit (MFU) (To be completed by the commissary owner, attach with your ...
My commissary is well maintained and in compliance with the requirements of Beaumont Health. Department (BPHD) Environmental Health Division and the Texas ...
Environmental Health AFFIDAVIT Central Preparation Facility (CPF)/Commissary for Mobile Food Unit (MFU) (To be completed by the commissary owner, attach with your Food Permit Application) MOBILE FOOD UNIT OWNER INFORMATION Name: ____________________________________________________ Phone/Mobile: ___________________________ Home Address: _____________________________________________________________________________________ E-Mail Address: ____________________________________________ Web Site: _______________________________ DBA: _____________________________________________________________________________________________ License Plate Number: ______________ Vehicle Make/Model: _____________________________________________ RESTAURANT/CENTRAL PREPARATION FACILITY/COMMISSARY OWNER Name: _______________________________________________ Phone/Mobile: ________________________________ Commissary DBA: __________________________________________________________________________________ Commissary Address: _______________________________________________________________________________ Commissary Contact: ___________________________________ Phone Number: ______________________________ I hereby declare that _________________________________________ @ ______________________________________ (Name) (MFU DBA) has my permission to use my approved commissary, _________________________________________________________ (Central Preparation Facility/Commissary DBA) located at __________________________________________________________________________________________ . "Promoting healthy lifestyles, preventing disease, and protecting the health of our community" Office: (409) 832-4000 Fax: (409) 832-4270 3040 College St Beaumont, Texas 77701 kenneth.coleman@beaumonttexas.gov AFFIDAVIT Central Preparation Facility (CPF)/Commissary for Mobile Food Unit (MFU) Page 2 My commissary is well maintained and in compliance with the requirements of Beaumont Health Department (BPHD) Environmental Health Division and the Texas Food Establishment Regulations, and will provide the MFU the following approved facilities/services: (Items already checked are mandatory): Adequate facility for storage of food, utensils and other supplies ________ Adequate facility for storage of MFU at the end of the day or when not in use Adequate facility for the sanitary disposal of garbage and liquid wastes ________ Adequate facility for food preparation (if food is not prepared on the truck) Note: Food may not be prepared at home Potable water for filling water tanks Hot and cold water under pressure for cleaning and sanitizing Equipment is NSF approved (Walk-in coolers, freezers, etc...) Approved janitorial sink, toilet, utensil washing, and hand washing facilities with single service soap and paper towels in dispensers I, _______________________________________________________________, Central Preparation Facility/Commissary owner, agree to notify BPHD Environmental Health Division at 409-832-7463 if the above mentioned MFU has discontinued its CPF/Commissary use or has not utilized this CPF/Commissary per operational requirements. I certify under penalty of perjury that I am the legal owner/operator of this facility and abide by the contents of this agreement. I am aware that my Health Permit as Central Preparation Facility/Commissary may be jeopardized if found to be in violation of this permit. ____________________________________ _______________________________ ____________________ Print Name Signature Date NOTE: I also understand that as a Central Preparation Facility/Commissary for a mobile food unit, I will be inspected for accurate documentation of the MFU's service log. STATE OF ______________________________________ COUNTY OF ____________________________________ AFFIDAVIT Central Preparation Facility (CPF)/Commissary for Mobile Food Unit (MFU) Page 3 Subscribed and sworn by ______________________________________________________________________ before me on this ___________ day of ___________________________, 20 _______. ________________________________________________ Signature of Notary Public or authorized official/officer ________________________________________________ Printed name of Notary Public or authorized official/officer (SEAL) BELOW IS FOR OFFICIAL USE ONLY: Current Health Permit Available: YES or NO Attach copy of current health permit. Current Inspection Report Available: YES or NO Attach copy of current inspection report. Approved by BPHD: ___________________________________________ Health Inspector _________________________ DateMicrosoft Word 2016 Microsoft Word 2016