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=� "N. SANADAQUIN Environmental Health Department <br /> 's.'"` —COUNTY— <br /> 114 Greotness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> ►�FO Business Name: !Ar Name Oats: Imo_ <br /> c 55 rV�l r rnu � �� ,r v�na <br /> CFO Physical Add s: CFO CityCFO Zip: <br /> 2aG - 202-64-7 <br /> 3 <br /> Webelte(if applicable): Telephone: <br /> 1. Categories: <br /> 'Class A"(Direct Sales Only)$155 ❑ "Class 8'(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 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-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 pace'if needed). <br /> Food List dt�� (,� e UCliar CZz,kl AJ1 <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 /> [.City Water ❑ 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 certfication 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 952051 T 209 468-3420 1 F 209 46"138 1 www.sjcehd.com <br />