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>b <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)4640138 Web:www.socehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> Abhv&.4wricagy, TreafsdCIAfs Sesf. Mct)rlt7h 113167 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> b69 7f, fsfaia Cliele b4beldmi, CA '15 <br /> Website(If applicable): Tel one: <br /> &2 9a3- R83Sev <br /> 1. Catestories: <br /> ❑ "Class A" (Direct Sales Only) $125 Er "Class B"(Direct& Indirect Sales)$250 <br /> $. 16_Mhibited 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 /> growth that could be a cause of food-bome 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). 1 _ / <br /> Food List:0�6Y1 Y r'P d (Ra NtGih /�tr 7)h7)h �&4 rdl/Inl\)®� <br /> 1171 �`.ej 1-rOfl./(9 Cqn,k I? 3 (Ma rn. rwh� <br /> y� �r Aes r- <br /> (9cJ e O 'Dry RiAks 4,r mexf') <br /> To't .s rwIG'eS l <br /> Sem.- a4+ad\edisf or. / fi1� s�ices ors �c <br /> 4. Product Labelin-cr \J <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 /> City Water ❑ Private Well* <br /> *If a private well,attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> EHD 16-29 6/29/2015 1 _ CFO REG/PERMITTING RENEWAL FORM <br />