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SQNJOQQUIN Environmental Health Department <br />—COUNTY— <br />L_ <br />-., Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Name: <br />tQ <br />CFO Physical Address: CFO Ci <br />V CFO Zip: <br />Website (Ir applicable): Telephone: <br />1. Categories: <br />K "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 />4. <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 neeyydedd). y/- <br />Food List: A- QI^1CAh -bccAA.yrCre p, -r -�,C" t�7 J k.�t�i+' C vee ✓r. <br />/r: kQA - Ucvl' 1 �c 1 -Sl" 't-1 Z r'o w r -r -e4 <br />VVta.L row <br />c kt,t - YVW,wJ-- I L2t�on S���c.�vorr� l Coconwt'- <br />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 />S. Water Source: <br />Please check what type of water source is being used at the CFO: <br />U City Water <br />❑ 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />61 <br />