Florida Commissary Letter Of Agreement Form PDF Details

The Florida Commissary Letter of Agreement form is a critical document for individuals operating mobile food establishments or self-vending ice units within the state. Managed by the Florida Department of Agriculture and Consumer Services' Division of Food Safety, this form acts as a bridge, ensuring that such businesses meet specific health and operational standards by affiliating themselves with an approved commissary. The form gathers detailed information on the mobile food establishment or self-vending ice unit, including ownership details and the scope of operations. It requires the owner to certify the accuracy of provided details and acknowledge the condition that permit approval hinges on the verification of the affiliated commissary's credentials. The form further delves into the specifics of the primary commissary, capturing vital details like the commissary's name, address, license number, and the types of services it will provide to the mobile unit, ranging from food storage to waste disposal. By signing the agreement, both the mobile unit and commissary grant food inspectors permission to evaluate the facilities, ensuring compliance with health standards. This form is indispensable for operators seeking to navigate the regulatory landscape of mobile food vending or ice vending, as it outlines the partnership and operational expectations between the mobile unit and the commissary, streamlining the permit application process.

QuestionAnswer
Form NameFlorida Commissary Letter Of Agreement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescommissary lease contract, commisary letter of agreement florida, dept of ag fillable pdf for commissary, commissary agreement letter florida

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Florida Department of Agriculture and Consumer Services

Division of Food Safety

COMMISSARY LETTER OF AGREEMENT

Bureau of Food and Meat Inspection 3125 Conner Boulevard C-26 Tallahassee, FL 32399-1620 (850) 245-5520

ADAM H. PUTNAM

COMMISSIONER

This form is to be filled out and given to the FDACS inspector in the field and submitted as part of a mobile food establishment permit application or with a package ice plant self-vending permit application that requires a commissary.

SECTION 1– MOBILE FOOD ESTABLISHMENT (MFE) OR SELF VENDING ICE UNIT (SVIU) INFORMATION

 

 

Owner Name

 

 

 

 

 

 

 

 

 

Phone Number (include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner Mailing Address

 

 

 

 

 

 

 

Permit Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Zip Code (+4 optional)

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify the provided information is correct and understand permit approval is contingent upon verification of an approved commissary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name (Owner of MFE or SVIU)

 

 

 

 

Signature (Owner of MFE or SVIU)

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 – PRIMARY COMMISSARY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Commissary Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commissary Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Zip Code (+4 optional)

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Phone Number (include area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commissary License/Permit Number

 

 

Primary E-Mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensed By

 

Department of Agriculture & Consumer

 

Department of Business and

 

Department of Health

 

None

 

 

(check one)

 

Services

 

 

 

Professional Regulation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Water Supply of Primary

 

Municipal/Utility

 

Supplier Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commissary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On-site Well

 

 

Permit Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Municipal/Utility

 

Supplier Name

 

 

 

 

 

 

 

Wastewater Disposal of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Septic Tank System

 

Permit Number

 

 

 

 

 

 

 

Primary Commissary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Package Plant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I intend to provide the following activities at this commissary:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dish or equipment washing

 

Yes

No

 

 

Storing of food and dry goods (room temperature)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dumping wastewater

 

 

 

Yes

No

 

 

Cold Storage of food (including ice and drinks)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receiving potable water

 

Yes

No

 

 

Cooking and/or reheating food

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Washing the outside of the vehicle

 

Yes

No

 

 

Three compartment sink

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Restroom facilities

 

 

 

Yes

No

 

 

Other (Describe below)

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe other activities here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signing this document will allow FDACS Food Inspectors entry to my business during normal hours of operation for evaluation of facilities.

 

 

 

 

 

 

 

 

 

 

 

 

Print Name (of Person in Charge of Commissary)

 

 

Signature (of Person in Charge of Commissary)

 

Date

 

 

 

 

 

 

 

 

 

 

 

Are additional commissaries used?

Yes

No

If yes use as many pages as needed.

 

 

 

 

 

FDACS-14223 Rev. 10/15

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Step # 1 for completing dept of ag fillable pdf for commissary

2. The subsequent part would be to fill in the following fields: Licensed By check one, Department of Agriculture Consumer, Department of Business and, Services, Professional Regulation, Department of Health, None, Water Supply of Primary Commissary, MunicipalUtility, Supplier Name, Onsite Well, Permit Number, MunicipalUtility, Supplier Name, and Wastewater Disposal of Primary.

Licensed By check one, Supplier Name, and Department of Agriculture Consumer of dept of ag fillable pdf for commissary

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