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0 SAN:JOAQUIN Environmental Health Department <br /> 4� < ----COUNTY----- <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> P%k= 'S S 1A! E 1�77 W P'- A MC>jL'CZ �— <br /> CFO Physical Address: t CFO—City: CFO Zip: <br /> 3� 92 is.1 <br /> VUebsite(If applicable) Telephone: <br /> 1. ate ories: <br /> X__ -Class A (Direct Sales Only) S155 ❑ 'Class B" (Direct& Indirect Sales) 5310 <br /> 2. Prohibited Iterns: Initial if you agree to abide by the following: <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br /> foods that are defined as "non-potentially hazardous are approved for preparation by a Cottage Food Operation. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> 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 of <br /> ingredients (attach separate page if needed). <br /> Food List: CAVO-, r-ky-C fops '-- Ckrce C'es J MzS <br /> Cv c LS _ ` w"1vim Coc)1L <br /> C_ooc­ - C_v G=Ze D , Acc- tz�5��� 1Ar_aCiS r 1�1z`t2G1- S , Oar , htuVt'KL-1 LIVJS <br /> - C NC•C��CC7 C.,y2D -ti!RtLwws �jQ CNOC-Lk-CG CI�([J <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 product is <br /> made). <br /> 5. Water Source: <br /> Please check what type of tauter source is being used at the CFO: <br /> *City WaterF1Private Well' <br /> f <br /> 'I 'a' private well. attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: <br /> Attach food handler certification for owner and each individual that were not submitted with initial application <br /> (including family members and/or employees). <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 465-3420 1 F 209 464-0138 1 www.sjcehd.com <br />