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09/20/2021 <br />I <br />09:32 2092346834 BASS FAMILYL <br />PAGE 01/02 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERIMITTING RENEWAL FORM <br />�FO Business Name: Owner Name: Da11 z <br />S�TEyr'S /l�ftcJ �S%'�V� SSS G� - <br />CFO Physical Address; , CFO City: CFO Zlp. <br />C/RcLr- ._S %UC)CrOAJ %s 2 a6 <br />Website(if applicable): Telephone' G <br />(14) 20 <br />I. cage n® <br />ries'. <br />"Class (Direct Sales Only) $155 I] ,Class B" (Direct & Indirect Sales) $310 <br />t. Prohibited Items' Iii 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 page if needed). <br />Food List <br />Vic% /GAll� .fir/' w�"rtJALJvv>' GOQ2 ic=y <br />4. Product Labeling: <br />Attach two labels to this form for two of your CI"O products (only one label is required if only one product is <br />made). <br />5. wator Source: <br />Please check what We of water source is bein<I used at the CFO: <br />[City Water ❑ Private Well" <br />`if a private well, attach all updated water samp a 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 />.� r k <br />