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1. S A N',J 0A 0 U I N Environmental Health Department --COUNTY Greatness grows here. COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING RENEWAL FORM F Businesaa me: Owner Name: Dau s I��d t�ti �� ,1�u f r� t,11 r- t Dar: /8 CFO Physical Address: CFO City: CFO Zip: �- Website(If applicable): Telephone: 1. Categories: "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 2. Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food-borne illness. 3. Products: Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list of ingredients (attach separate page if needed). Food List: cerci nct C'al � V�'t fl i Ila� 11.- z o Cate e �i i211��,61e e& re �'L�.i� dA-�U 6-p lL'S, '?1-e 1 Ore 0 , rI ce �V/ 4. Product Labeling: Attach two labels to this form for two of your CFO products (only one label is required if only one product is made). 5. Water Source: Please check what type of water source is being used at the CFO: City Water ❑ Private Well* *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) 6. Food Processor Course: Attach food handler certification for owner and each individual that were not submitted with initial application (including family members and/or employees). 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com V Vo .5�11 Iq S