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SANJOAQUIN <br />—COUNTY— <br />Greatness grows her <br />�-11� oo2.b32g f SOS4by49 <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) JAN 03 2022 <br />REGISTRATION/PERMITTING RENEWAL FORII VIRONM NTALH ALTH <br />PERMITCFO Business Name: 1'"erg Owner Name: MUAi� AW Date: 0/ /lfjZy <br />CFO Physical Address: CFO City: CFO Zip: <br />7- 1p)oos"AA fit 1+cl,1,�t.vL ruP 95_530 <br />Website (If applicable): Telephone: <br />5WUA- – Gin•lers, r ovin �25-SSI -/fo3� <br />1. C ories: <br />Class k" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: AA A <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 />CU 'j1wt+ <br />to -C1`&5 TaOAS <br />03 °u YI11(K1 <br />(5-1 AU. $X043 k4MC <br />Wla&- <br />w p cauzS0 rVVJJ_ VVA4I <br />uleLcl <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 />plea 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.sjcehd.com <br />