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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION (Contra Costa Health Services)

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 200
CONCORD, CA 94520
(925) 692-2500 (925) 692-2502 FAX
http://cchealth.org/eh
REV DATE: 3/24/2017
PRODUCTION KITCHEN AGREEMENT
FOR CATERE R S
1. TO BE COMPLETED BY OWNER OF CATERING BUSINESS
Owner Name:
Name of Catering Business:
Owner Address:
City:
State:
ZIP:
Cell Phone:
Email:
I will notify Contra Costa County Environmental Health, by written document, of any change in the status of my operation or
when the Production Kitchen contract is terminated.
I hereby state that the above information is current, true and correct to the best of my knowledge and agree to use the
Production Kitchen in accordance with the California Health and Safety Code.
This agreement will expire at the end of each permit year and must be submitted annually, along with the Caterer Business
Permit to Operate Application.
Signature: ___________________________
Print Name: ___________________
Date: _____
2. TO BE COMPLETED BY PRODUCTION KITCHEN OWNER OR OPERATOR
Type of Facility: Restaurant Production Kitchen
Name of Production Kitchen:
Facility Address:
City:
State:
ZIP:
Owner Name:
Email:
I agree to provide to the above mentioned applicant access to the following:
Hand washing facilities
Food preparation area
Food preparation sink
3-Compartment warewash sink
Refrigeration/Freezer storage
Cooking equipment and ventilation hood
Ice machine or cooling equipment
Potable water
Garbage and refuse disposal
Dry food/equipment storage
Chemical storage
Restroom with hand washing facilities
I hereby declare that I hold a valid Environmental Health Permit to operate a Production Kitchen. (Include a copy of a valid health
permit). I certify that the business named in section 1 is operating out of the above Production Kitchen.
I will notify Contra Costa County Environmental Health Division by written document of any change in the status of my operati on,
my environmental health permit, or when this Production Kitchen/Approved Facility agreement is terminated.
Signature of Owner/Manager: ___________________________
Print Name: ___________________
Date: _____
3. OUT OF COUNTY PRODUCTION KITCHEN (SIGNED BY AGENCY WITH JURISDICTION)
Food Establishment is permitted in______________________________________________ County.
Enclose a copy of valid Environmental Health (EH) Permit and obtain a signature from an authorized EH inspector from that county.
The above checked (see section 2) requirements are available at the proposed Production Kitchen/approved facility.
REHS Signature: _____________________
Print Name:__________________
Phone:_________
Date:______
FOR OFFICE USE ONLY
FA#:
PR#:
PE: 0622
Received By:
Date Received:
REHS:
Date:
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CONTRA COSTA ENVIRONMENTAL HEALTH DIVISION (Contra Costa Health Services)

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Completed 9 February 2021

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