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SELF rte• 'r"eKATInkic- <br /> SAN JOAQUIN Environmental Health Department <br /> r_C?I [,dT r <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CSO Business Name Owner NameDate <br /> CFO PhysiAddress. CFO City CFO Zip <br /> • � � _� � l <br /> Website(If applicableTelephoned 0 <br /> 1. Categories: <br /> "Class A"(Direct Sales Only) 5155 ❑ Class B' (Direct& Indirect Sales) 331c) <br /> 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. Only <br /> r 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: <br /> u�L Co —1� ►—_ r`off( 1 C i 2cr___-- —- ----— -- <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 water source Is being used at the CFO- <br /> 0 City Water <br /> ❑ Private Well' <br /> 'Ifa 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 209 468-34202 _ <br /> � F 09 464 0138 1 '^"I't`^'.sjcehd.com <br />