{"id":2185,"date":"2025-04-24T13:19:32","date_gmt":"2025-04-24T17:19:32","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/norfolk\/?page_id=2185"},"modified":"2025-04-24T13:36:09","modified_gmt":"2025-04-24T17:36:09","slug":"commissary-agreement","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/norfolk\/commissary-agreement\/","title":{"rendered":"Commissary Agreement"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/norfolk\/wp-json\/wp\/v2\/pages\/2185' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_6_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Instructions<\/h3><div class='gsection_description' id='gfield_description_6_7'>Commissary Owner\/Operator: Complete this form and provide the Mobile Unit a copy of your current health department permit and last health inspection report.\n\nMobile Unit Owner: Submit this form, the Commissary's health department permit, and last health inspection report along with your Mobile Unit Permit Application.<\/div><\/div><div id=\"field_6_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Mobile Unit Information<\/h3><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_17'>License Plate #:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_6_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Owner Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_18\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_6_18' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Commissary Information<\/h3><\/div><div id=\"field_6_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_23'>Commissary Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_6_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_22\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Commissary Owner\/Manager Name:<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_22'>\n                            \n                            <span id='input_6_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_6_22_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_22.3' id='input_6_22_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_6_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_6_22_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_22.6' id='input_6_22_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_24'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_6_24' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_25\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_25'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_6_25' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_6_4\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_6_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_4_1_container' >\n                                        <label for='input_6_4_1' id='input_6_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_4.1' id='input_6_4_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_4_2_container' >\n                                        <label for='input_6_4_2' id='input_6_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_4.2' id='input_6_4_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_4_3_container' >\n                                    <label for='input_6_4_3' id='input_6_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_4.3' id='input_6_4_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_6_4_4' value='Virginia'\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_4_5_container' >\n                                    <label for='input_6_4_5' id='input_6_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_4.5' id='input_6_4_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_6_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_26'>Health Department Permit (provide copy) Issued by:<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_6_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Commissary Services<\/h3><\/div><fieldset id=\"field_6_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequency of services provided to the Mobile Unit:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_28'><div class='gchoice gchoice_6_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Daily'  id='choice_6_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_28_1' id='label_6_28_1' class='gform-field-label gform-field-label--type-inline'>Daily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Weekly'  id='choice_6_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_28_2' id='label_6_28_2' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Other'  id='choice_6_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_28_3' id='label_6_28_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Services that will be provided (select all that apply):<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_29'><div class='gchoice gchoice_6_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Approved potable water source'  id='choice_6_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>Approved potable water source<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Wastewater\/refuse disposal'  id='choice_6_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_2' id='label_6_29_2' class='gform-field-label gform-field-label--type-inline'>Wastewater\/refuse disposal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Cleaning area for Mobile Unit'  id='choice_6_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_3' id='label_6_29_3' class='gform-field-label gform-field-label--type-inline'>Cleaning area for Mobile Unit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Overnight parking for Mobile Unit'  id='choice_6_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_4' id='label_6_29_4' class='gform-field-label gform-field-label--type-inline'>Overnight parking for Mobile Unit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Overnight refrigeration'  id='choice_6_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_5' id='label_6_29_5' class='gform-field-label gform-field-label--type-inline'>Overnight refrigeration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='Food preparation area'  id='choice_6_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_6' id='label_6_29_6' class='gform-field-label gform-field-label--type-inline'>Food preparation area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='Food storage area'  id='choice_6_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_7' id='label_6_29_7' class='gform-field-label gform-field-label--type-inline'>Food storage area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Utensil washing area'  id='choice_6_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_8' id='label_6_29_8' class='gform-field-label gform-field-label--type-inline'>Utensil washing area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.9' type='checkbox'  value='Equipment and utensil storage area'  id='choice_6_29_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_9' id='label_6_29_9' class='gform-field-label gform-field-label--type-inline'>Equipment and utensil storage area<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_29_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.11' type='checkbox'  value=''  id='choice_6_29_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_29_11' id='label_6_29_11' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Certification<\/h3><div class='gsection_description' id='gfield_description_6_30'>I give the Mobile Unit listed above permission to use my establishment. 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