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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ..: '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:wwwa cehd.com <br /> �c, s P <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING REN <br /> i <br /> DateOwner : <br /> z <br /> .Name: Ip��� !_ <br /> CFO Business Name: ` fpr l <br /> 2� � ek 1 '� CFO Zip: <br /> CFO City: �I <br /> CFO Physical Address: <br /> e- <br /> 1� 7 <br /> Telephone: <br /> Website(If applicable): <br />{-------------- <br /> E <br /> 1. Cate 12lies.. <br /> E]"Class A" (Direct sales Only) $133 <br /> "Class B" (Direct&indirect sales) $265 <br /> 2. Prohibited items: initial if you agree to abide by the following: <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br /> Only foods that are defined as"non-potentially hazardous" are approved for preparation by a Cottage Food <br /> Operation. These foods include items. that'do not require refrigeration to keep them safe from.bacterial <br /> i growth that could be a cause of food-borne illness. <br /> 3. Products <br /> Provide a list of all products you are preparing- If preparing jams,jellies, or fruit butters include a list <br /> of ingredients (attach separate page if needed). <br /> is <br /> Food List: hio A. <br /> a <br /> i <br /> E <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one <br /> product is made). <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> 1K City Water ❑ Private Well* <br /> *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> FHD 16-2913/12/2016, 1 CFO REG/PERMITTING RENEWAL.FORM <br />