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SAN lOAQUIN <br /> Environmental Health Department <br /> -COON <br /> COTTAGEGE FOOD OPERAT IONS (CFO) <br /> T ONIPERMI T G RENEW'` FORM <br /> REGtSTRA Date: <br /> owner Name: w <br /> RaWness Nsme: f c0- CFO zip: <br /> Oalttlnwse Vt� FO <br /> CFO P"Ical Address: Oil[�Q i Y1 <br /> Teleph ne: �p O r <br /> Website(If applicable): `� O <br /> 1. C�te�_ 90'7es- ❑ -Class B"(Direct&indirect Sales)$310 <br /> "Class A" (Direct Sales Only) $155 <br /> Initial if you agree to abide by the following: <br /> 2. Prohibit_ ed I ems: a Food Operation. <br /> Foods containing cream, custard, or meat fillings are potentially or preparation <br /> rehazardous byaa NOT ALLOWED. Only <br /> foods that are defined as°non-potentially hazardous are approved far p p <br /> growth that could be a <br /> These foods include items that do not require refrigeration to keep them safe from bacterial <br /> cause of food-borne iiiness. <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 /> -- -- <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 handier 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' T 209 468-3420 f F 209 464-0138 j www,sjcehd.com <br />