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PCZ 51=0185Z <br /> M <br /> SANAOAQUIN Environmental Health Department <br /> F" mkt —COUNTY <br /> C "' Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO slness Name: Owner Nam Date: <br /> CFO Physical Address: CFO City: CFO Zip: <br /> I �T�ESI �'a�a.LS� TIDG�1 QS' -, <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $155 [Class B" (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 /> du'rS u40'ulule9'epu0w1tl <br /> 3. Products: '1ensue 'wlwpaouapuoo <br /> (ellluen aIDd'u141!0al peualewes'hive•ween <br /> Aos,jProvide a list of all products you are preparing. If preparing ams, ellie, esignq eooW'JB6nS) pezumsedpeDns '(elnuee <br /> p Y P P 9 P P g l 1 iepnq e000�'seBns) teal amd vlylloal esoc•lonbll <br /> ingredients (attach separate page if needed), e1e100043'spu0WIV eliaeo Ueunq eo oa <br /> 'seBnS 7e1)ns:swalpaJBul Beane) I �y0:egmipwoul <br /> Food List: 9o9t-2¢9(6o2) 908e-zee(602) <br /> A��aS �octt wms>IgpslsmgrvuuaVaaaua �saanislewgselue000o euue <br /> 7 pip <br /> /c' (� waJY>lgRfMlf>LISPYea'MMM IQllslswlsewe'-NAM <br /> ^� ulnbearu¢s 9Led 19081 <br /> y-s�-`s,, 1 \ /auno'J Ulnbeor peoy eslpWed La68l <br /> 5 � ueS 9GE96'V0'A0wl UGWIDI ewoH PeAWO <br /> rV�. a� peon eslpeled iM L e UI Valens=4 spun <br /> e ul 401woS wos)epeyq <br /> 600DIso BW NCA y>m WORIAI <br /> 4. Product Labeling: ANNA's <br /> 5STARBAR <br /> namel <br /> Attach two labels to this form for two of our CFO products (only one lat ne ' tested <br /> Y P ( Y * Whole Toasted Almondz <br /> made). AA'�i * Fudge <br /> I3�Ra S TIB1 ES *Anna's Row <br /> 5. Water Source: 60aD1F5Me1 W9Cn y>s WaRUDI *Homemade Marshmallow <br /> DipDark Chocolate Apped In Milk Chocolate <br /> Please check what type of water source is being used at the CFO: Mpo992233ximmely 3.6 s)«s <br /> YP g ANNA'S ROCA (99.2433 grams) <br /> ❑ City Water ivate Well* V2 pound(226.79 9) <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 /> S <br />