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RS S <br /> � '• - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT #X, <br /> f: a <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232. 4t*, ,3� <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjcehd.camp �l <br /> i <br /> 414 <br /> CFS h <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> -c-AXAM ffi&L4 ,� <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 5951 E, Ynf �✓� -` � -- �s" 1 <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> ❑ "Class A" (Direct.Sales Only) $125 ( "Class B" (Direct& Indirect Sales) $25IT- <br /> I 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 /> -- <br /> growth-thatccould=be-a=cause=of food borne iEIness <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 /> Food List: , <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 /> ❑ City Water Private Weil" <br /> 'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> EHD 16-29 612912015 1 CFO REGIPERMITTING RENEWAL FORM <br />