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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:www.sicehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> RUC r. criAMCA Its }}, 4-Z-it( <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 30115% w is� S!V%ey%4. " l n� qS 29A Z. <br /> Website(If applicable): Telephone: <br /> Sarge.n.}-reonl Comp n� m-4wi 'l cevH. 20°x• y$2-'�18� <br /> u <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $146 "Class B" (Direct & Indirect Sales) $292 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: 'U* <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-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 /> Food List: <br /> `1e 7 Ce`i ' 1pvow ry SuAce�^ b u� cy k C.orh �v`�v v d <br /> V lx V+ 16&kL A a Soot a� <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 Well* <br /> *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> EHD 16-297/27/17 1 CFO REG/PERMITTING RENEWAL FORM <br />