Form FDACS-14223 at a glance
What it is: Form FDACS-14223 is the Commissary Letter of Agreement of the Florida Department of Agriculture and Consumer Services, Division of Food Safety.
Where and when to file: 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.
A filled-in Form FDACS-14223 example: a food truck owner names a commissary
How to fill out Form FDACS-14223, box by box
Section 1: Mobile Food Establishment (MFE) or Self Vending Ice Unit (SVIU) Information
In Section 1, Mobile Food Establishment (MFE) or Self Vending Ice Unit (SVIU) Information, enter the Owner Name, Phone Number (include area code), Owner Mailing Address, Permit Number, City, Zip Code (+4 optional) and County.
Owner certification and signature
You certify the provided information is correct and understand permit approval is contingent upon verification of an approved commissary.
Enter the Print Name (Owner of MFE or SVIU), add the Signature (Owner of MFE or SVIU) and enter the Date.
Section 2: Primary Commissary Information
In Section 2, Primary Commissary Information, enter the Primary Commissary Name, Commissary Address, City, Zip Code (+4 optional), County, Primary Phone Number (include area code), Commissary License/Permit Number and Primary E-Mail Address.
Licensed By (check one)
Under Licensed By (check one), check Department of Agriculture & Consumer Services, Department of Business and Professional Regulation, Department of Health or None.
Water Supply of Primary Commissary
Under Water Supply of Primary Commissary, check Municipal/Utility and enter the Supplier Name, or check On-site Well and enter the Permit Number.
Wastewater Disposal of Primary Commissary
Under Wastewater Disposal of Primary Commissary, check Municipal/Utility and enter the Supplier Name, check Septic Tank System and enter the Permit Number, or check Package Plant.
Activities at this commissary
I intend to provide the following activities at this commissary: mark Yes or No for Dish or equipment washing, Storing of food and dry goods (room temperature), Dumping wastewater, Cold Storage of food (including ice and drinks), Receiving potable water, Cooking and/or reheating food, Washing the outside of the vehicle, Three compartment sink, Restroom facilities and Other (Describe in the Describe other activities here box).
Describe other activities here.
Person in Charge of Commissary
Signing this document will allow FDACS Food Inspectors entry to the business during normal hours of operation for evaluation of facilities.
The Person in Charge of Commissary enters the Print Name, the Signature and the Date.
Additional commissaries
Are additional commissaries used? Mark Yes or No. If yes use as many pages as needed.
Sources
[1] Form FDACS-14223 (Rev. 11/18), Commissary Letter of Agreement, Florida Department of Agriculture and Consumer Services (the Official source link on this page).