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SAN J OA Q U I N Environmental Health Department <br /> COUNTY <br /> IPO 05%15238 <br /> 1 Fame <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name:�p{dot p Owner Name: �� `3� <br /> T7 T�.rTI <br /> CFO Physical Address: CFO Cil,. CFO Zip: y�� �{ <br /> IIS _ r�,� �E (0U�"tr <br /> Website(Ir applicable): Telephone��� <br /> 1. Categories: V l <br /> ❑ "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: <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-bome 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: 0�-M 1 <br /> Y� W S 1,0 AK 5 <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 /> EA 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 andlor employees). <br /> 1868 E. Hazelton Avenue j Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcelid.com <br />