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PJ� O's uYg2-j- <br />SAN JOA 0 U I N Environmental Health Department <br />IJ I", <br />S`: 2 3 27 <br />COTTAGE FOOD OPERATIONS (CFO),, lizoNNIENTAL nEALI II <br />REGISTRATION/PERMITTING RENEWAL FORWEPARTMENT <br />CFO Business Name: Owner Name:Date: <br />" Pial=etch-i � 12Uq <br />AW <br />q l.�P t�('�i�• G'u 2 9.3D. <br />.3y. al <br />CFO Physical Address. CFO City: CFO Zip: <br />Ioaf"I l.aKteQ L4,x S-ZCk gS-ai <br />Website (If applicable): Telephone: (.PZ q) 30 0 _ -71 CL9 5- <br />1. Categories: <br />0—=`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: AZL <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 -borne 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 />.SuQW CooY--�eS , C- K&r-11g2.f(LA O rW,- - �grr,,Lk <br />Hl)tCo cow- bor-~bs <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 />�ty 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 />a Dch%_,\ o.(l yr\ON. \ . corn S <br />