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SAN J OAN I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO auslnass Name. Omar Name: D.81/1912022 <br /> Briltney's Cookie Creations Briltney Mancilla <br /> CFO Physical Address: CFO City. CFO 7i <br /> 21687 McBride Rd Esralon 95320 <br /> Website(If applicable): Telephone' <br /> 209-681-7611 <br /> 1. Categories: <br /> ® "Class A"(Direct Sales Only)$155 ❑ "Class B"(Direct 8 Indirect Sales)$310 <br /> 2. Prohibited Items: Initial 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-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 /> See Attached Food Label <br /> l2'1/ <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 wafer source is being used of the CFO: <br /> ❑ City Water I] 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 /> individual that were not submitted with initial application <br /> Attach food handler certification for owner and each <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 />