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1F P, 00 2b `'1 �)o <br />P� 05 1 Lobs <br />SAN JOAQUIN Environmental Health Departmen <br />COUNTY <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Business Name:51.�/�--� Owner me; T De: <br />Y%- P�5� S �..n JCS �L— `Q % <br />CFO \ � I�df lss: CFO IryCFO Zip:�� <br />Website (If applicable): Telephone: <br />1. C ories: L <br />"Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: <br />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 />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 />Ple a 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 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.sjgov.org/EHD <br />c a \ � 'Swee-t 96% @ �jo,,1r.,Y0. c-om <br />