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SANA0AQUIN p <br /> Environmental Health Department <br /> COUNTY— G3C � �VC oD <br /> cgtP Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) JUN 0 7 2021 <br /> REGISTRATION/PERMITTING RENEWAL FOPWNMENTAL HEALTH <br /> RMIT/SERVICES <br /> CFO Business Name: r Owner Name: Date: <br /> 11 Ckala siILept 5-2&- 20ZI <br /> CFO Physical Address: CFO City:, CFO Zip: <br /> I-71-7I 4 Tore,+62,08 4 QJ dro&ke Fard , 04 q'57-3 7 <br /> Website(If applicable): Telephone: <br /> 1. Categories: S�9le/ cher e(� �C,1� <br /> F-1 "Class A" (Direct Sales Only) $155 -Class B" (Direct& Indirect Sales) $310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: 00 <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 page if needed). <br /> Food List: <br /> Ou e_A Re6 -- 1�ru t� Pou.rt 6 uqg r. 6ct,14 <br /> �.�t�o5 Com s tr <br /> Cherie Segler <br /> 17971 N Tmtheway Rd <br /> Lockeford,Ca 95237 <br /> v+u� <br /> thane,mo Unftmte,letlflavIn,and <br /> flour,nladn.rettucedSug Iron. <br /> thiamine,monutenin , omiden,.S folk acid). n,N Sugar. <br /> Vegetable shortenirg,CumsWrch,Selt,Cinnamon,Nutmeg <br /> 4. Product Labeling: Contains:wheat <br /> Attach two labels to this form for two of yow Made In A Home Kitchen <br /> made). Chene's Pies Permit#PT0025226 <br /> Issued In San Joaquin County <br /> 5. Water Source: Net M 2.51bs(40.0 oz <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 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 /> ?(2� s11 11� <br />