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SAN.DJOAQUIN <br />COUNTY <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />saie 8UpsRacieshd °weer Name Gynae Davalos Date May 24, 2021 <br />6T 1 d i kci6WPignola St 6kton 9g2643 <br />StigaRtligftd.conn Telephone: 20978790QQ <br />orders 5Lcyrtt.ia. corn <br /> <br />Categories: <br />10 "Class A" (Direct Sales Only) $155 0 "Class 6" (Direct & Indirect Sales) $310 <br />Prohibited Items: Initial if you agree to abide by the following: GD <br /> <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 />Baked goods <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 />Greatness groivs here. <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />12I 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