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} <br /> i 11V1/�I` l <br /> =�°P4C1. SKJ OAQ U I N Environmencali Health Department <br /> Q r. <br /> —COUNTY <br /> ,FORa�P' Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> a b urn; I v 1=61 ✓'m s barba,-,q N,.ck 94/1-o 8 1 s I t <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 1935O S. ack Tone Xd. Ha^ -cCa <br /> Website(if applicable): Telephone: <br /> Nle a ° �- 3�z� - u � � y o� .z0 �_ 32� -� 03 � <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: �J� lP4 <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: d. 5 ✓ ti r Fr uu� m Dn �Ju ) c <br /> ��G1 /11 � /n�jrrc �,en�S � , f e <br /> p e C fi n ,J1 u Ori e q <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 /> F-1 <br /> FO:❑ City Water x 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 />