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JN IN J UAQ U I IN Cnvironmeniai rlealun veparunent <br /> Cni INTY <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name Owner Name Da- <br /> U <br /> CFO Physical Address' CFO City CFO Zip• <br /> r- 6_J 2__ <br /> Website(If applicable) Telephone: <br /> F LA b%- U-1C1r5l-1 lv <br /> 1. Categories: <br /> 7" Class A" (Direct Sales Only) 5155 ❑ "Class B° (Direct & Indirect Sales) 6310 <br /> 2. Prohibited Iteliis: Initial if YOU agree to abide by the following: I � <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 /> F 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 /> eSS C,ak ce > b ru W YA 1 C-S , C�k� (2 6 P,:�> ----- <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 /> Pease 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 /> 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 ancVor employees). <br /> IM8 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 I www sicehd.com <br />