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<br />SANAOMMIN <br />COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />Po_ 0 sLi s ct <br /> c`z-irry <br />Nt4.1FOOP <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />Owner NI Thdbir oc_orro Date: --- it <br />q 12321 <br />CFO Physical Address: r <br />1 21 r\J-erTnno <br />CFO City:000u n_fa frkose I co) CFO Zip: <br />0,,s3cti <br />Website (If applicable): Telephone: <br />C te ories: bc,.\ b6r_socorro cOm <br />"Class K-(Direct Sales Only) $155 0 "Class B" (Direct & Indirect Sales) $310 <br />PZIS 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 />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 />Pe-pperticirv+ cooitt' <br />CorkiCiat cep 114.e3 <br />£75 <br />irkwc. <br />1 rn-erbire ad C,Dt))1-1 -e-0 <br /> <br />Choc&kk Orriunb-e btr1 <br /> <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 />Plea check what type of water source is being used at the CFO: <br />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