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t:7 (A � z <br />SAN 10A Q U I N Environmental Health Department <br />-- _(DurJ <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Ovmer Name: <br />CFO Physical Address: CVO City: CFO Z!p: <br />Website Qfa ;cable): v V Telephone: <br />lam- , lau l�v� ,eta Zo q. X55 l9 S j <br />1�. Categories: <br />p[� "Class A" (Direct Sales Only) $155 El "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 A WED. 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-bome 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: .'�VpkLE ,r <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 />Flese check what type of water source is being used at the CFO: <br />CRy Water ❑ Private Well* <br />*If aaa 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 />5 <br />