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SAN JOAQUIN Environmental Health Department —COUNTY— <br />Greatnes% hEvp <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFQ Business Name: Owner Name: Date: tPIG, t(?-er<I9 .5 5 &kart 0.71 1 ')--1 ariJI <br />CFO Physical Address: CFO City: CFO Zip 191 6 e-h5 t L-eNke-cf-k • Me---ici C_Ll <br />Website (If applicable): Telephone:( <br />Categories: <br />0 "Class A" (Direct Sales Only) $155 <br />"Class B" (Direct & Indirect Sales) $310 <br />Prohibited Items: Initial if you agree to abide by the following: 173 <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 />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 />to,A;ps ksi (Arts , <br />coo1/4 4,s fvm s mull, av)(6.t> <br />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 />Water Source: <br />Reese check what type of water source is being used at the CFO: <br />g City Water 0 Private Well <br />if a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />co\zuk51.4-5-2,3g <br />Food List: