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WATER SOURCE Potable water must be available at all times during the CFO for hand washing, ware washing, and for use as an
<br />ingredient. Select the water source for your CFO kitchen.
<br />Public Water System / F Private Water Source
<br />Name: _koI t,. (Contact Environmental Health prior to submitting this form)
<br />WASTE DISPOSAL Select your disposal method for sewage and gray water waste. In the event of a sewage back-up or septic system
<br />failure, you re required to notify San Mateo County Environmental Health and cease CFO until approved to reopen.
<br />r% Public Sewer System - Private Septic System
<br />PRODUCTS TO BE SOLD (select all that apply)
<br />Non -Potentially Hazardous Foods listed on the allowed only, typically food items that do not require refrigeration to keep them safe
<br />from causing illness.
<br />F Fruit Pies r Fruit Empanadas r Dried Pasta r Dry Baking Mix r- Nut Mixes Hard Candy (e.g., brittle, toffee)
<br />r Herb Blend r Dried Mole Paste r Fruit Tamales r Granola f Nut Butters r Chocolate Covered Nuts
<br />r Seasoning Salt r- Popcom r Vinegar r Trail Mix r Cereal Dried FmiWegetables
<br />r- Sweet Sorghum r Roasted Coffee r Dried Tea r' Mustard r Veg.IPotato Chips I -- Dried Veg.-Based Soup Mix
<br />F Cotton Candy r Candied Apples r Waffle Cones r Pizzelles r Ground Chocolate r Dried Grain Mixes
<br />F Caramel S- Fudge r Marshmallows r- Donuts r Waffles r Honey
<br />17L Other: Sq tyC CA, I)/
<br />IV Jam r Jelly r Preserves - Fruit Butter Must comply with the standard described in -
<br />r Bread r Biscuits r Chumas r Cookies f Pastries r Tortillas
<br />Baked goods with cream, custard, or meat fillings are not allowed.
<br />Note: Only buttercream frosting, icing, fondant and gum paste that do not contain eggs, cream or cream cheese are allowed.
<br />I ICT FXOCT PRODUCTS AND DESCRIBE THE PROCESS (attach additional sheets if necessary)
<br />STRAWBERRY .IAM INGREDIENTS:
<br />MADE IN A HOME KITCHEN, LODI, CA STRAWBERRIES, SUGAR
<br />PERMIT #0026950 S J COUNTY
<br />NET WT. 8 Oz. 227 GRAMS
<br />WHERE WILL THE FOOD BE SOLD?
<br />- Certified Farmer's Markets r Retail Food Facilities r Temporary Events ft Other:
<br />PRODUCT LABELING SAMPLE:
<br />All CFO products for sale must be labeled as per the Federal Food, Drug and
<br />Cosmetic Act (21 USC Section 343 at seq.).
<br />The minimum requirements include, but are not limited to:
<br />The words "Made in a Home Kitchen" in 12 -point type on the primary display panel
<br />The name commonly used for the food product or an adequately descriptive name
<br />,The name and address of the CFO which produced the cottage food product.
<br />The Record ID Number of the CFO issued by San Mateo County Environmental Health.
<br />-The permit -issuing agency, "County of San Mateo Environmental Health"
<br />• Ingredients, in descending order of predominance by weight (if two or more ingredients).
<br />,1 ATTACH A SAMPLE LABEL FOR YOUR CFO PRODUCTS.
<br />X (Renewing CFO's must submit the actual label being used)
<br />CFO OWNER AGREEMENT
<br />/MADE IN A HOME KITCHEN
<br />REGISTRATION/PERMIT4 PROOXXXXX
<br />CHOCOLATE CHIP COOKIES
<br />Jane's Baked Treats
<br />JANE SMITH 123 Main Street, Sunny, CA 12345
<br />San Mateo County Environmental Health
<br />Ingredients: Enriched flout (Wheat flour, niacin, reduced iron,
<br />amine, mononitrate, riboflavin and folic acid), butter (milk, salt),
<br />hacolate chips (sugar, chocolate liquor, cocoa butter, butterfat
<br />milk), soy lecithin, walnuts, sugar, eggs, salt, artificial vanilla
<br />extract, baking soda.
<br />Contains: Wheat, milk, soy, walnuts
<br />\ Net Wt. 3 oz. (85.0 g)
<br />BY SIGNING BELOW, I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE HEREIN ARE CORRECT AND TRUE. I HEREBY
<br />CONSENT TO ALL NECESSARY COTTAGE FOOD OPERATION INSPECTIONS MADE PURSUANT TO LAW AND INCIDENTAL TO THE ISSUANCE OF
<br />THIS PERMIT. I ACKNOWLEDGE THAT 1 MUST NOTIFY SAN MATEO COUNTY, ENVIRONMENTAL HEALTH OF ANY INTENDED CHANGES TO THE
<br />ABOVESTATEMENTS. I
<br />OWNER SIGNATURE: ` PRINT NAME: qZ� 7/fLt4DATE: S Mai
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