Fillable Florida Department of Agriculture and Consumer Services Division

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Florida Department of Agriculture and Consumer Services Division

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Florida Department of Agriculture and Consumer Services
Division of Food Safety
COMMISSARY LETTER OF AGREEMENT
Bureau of Food Inspection
3125 Conner Boulevard C-26
Tallahassee, FL 32399-1620
(850) 245-5520
NICOLE "NIKKI" FRIED
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
Zip Code (+4 optional)
County
Primary Phone Number (include area code)
Commissary License/Permit Number
Primary E-Mail Address
Licensed By
(check one)
Department of Agriculture & Consumer
Services
Department of Business and
Professional Regulation
Department of Health
None
Water Supply of Primary
Commissary
Municipal/Utility
Supplier Name
On-site Well
Permit Number
Wastewater Disposal of
Primary Commissary
Municipal/Utility
Supplier Name
Septic Tank System
Permit Number
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
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Florida Department of Agriculture and Consumer Services Division

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Completed 31 May 2021

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