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SAN J O A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: 9 <br /> et4.)v F4m: ly Fp�rn s /vfcr- Q 13uebas-g AA+-tv <br /> k <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 14 3 S C S. J"k-T` Act' P ar++ccex, 9583 <br /> Website(If applicable): Telephone: <br /> At A ;koq .411- 0634 - nr.'C/C- ,icq ad-/- 0930 barb,C <br /> 1. Categories: <br /> ❑ "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: 6 k, N� <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: J4 In fr.9r•adienf s - Sv,Arf /e/hon Jv cc, Pccfi'n ) nutmeg <br /> 04f/nca/ /(piSi'n e00Cief <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 Z'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 /> OZO"55W <br />