Once completed, this form must be printed, signed and then submitted to the appropriate City of Lewisville department along with any required fees.

COMMISSARY APPROVAL APPLICATION

Mobile Vendor

Push Cart

Ice Cream Truck

Commissary Name:
Address:

The mobile vehicles listed below have permission to use the services of my facilities:
Vehicle Name: (displayed on vehicle)	Permit #:	Owner of Vehicle: (name)

The following services may be performed at my commissary by the above units:
Has acces to the facility at all times.
Has limited access to the facility. If yes access hours are:
Has access to inside preparation facilities:
	Store mobile unit	Wash out vehicle	Fill with fresh water.
	Dispose of waste water	Wash, rinse, sanitize all food contact surfaces.
	Store excess product.	Store products requiring refrigeration.

Comments:

A copy of the commissary's most recent health inspection report and health permit must be provided prior to inspection. Commissary owner's signature must be notarized unless the commissary owner is present at the City of Lewisville at the time of signing.

Commissary Owner:
Signature		Print

Date:

Texas DL #:

DOB:

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II. Short Forms for Acknowledgement:
	(1) For a natural person acting in his or her own right.
STATE OF TEXAS		COUNTY OF (1)
This instrument was acknowledged before me on			by
(SEAL)
		Notary Public - Signature