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OP <br /> IN Ca <br /> f� ,\ SANAOAQUIN Environmental Health Department <br /> COUNTY <br /> �tOgttP Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: I, Owner Name: Dat <br /> r f C ()✓ 1-11,C Sc-w,c,t-.i P qo -11 ") 12-0 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 11 L4a Tct4 cA Lin Mc v,, J-ck cl S337 <br /> Nebsite(If applicable): Telephone: <br /> I .P�`--G,rk-5 Cti k.c S eow, ( 2oti) 1 NU - 2�3Z <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) $155 ❑ "Class 3" (Direct & Indirect Sales) $310 <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 /> 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 /> Ucl'�� cel c� � G6(_ c.c� I t � Con 6tAt , Le m o,-, , "iI�Z CCL/(.e <br /> Cc,,tuS) acvw x4 <br /> "ULAL Cr <br /> Cyy1 ki - LVlvc c�i� ��fCGr SGt. ✓ <br /> r v tG L NUwS rn�(A r y S — ShwrLO , G6C'_ � YY1Ar5�1 nt � q rC�lvi, ctkd .erS <br /> rQ rr - ! r CbrrlSk" <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 /> A 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 and/or employees). <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> P,�2 0611 <br />