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bg2 � <br /> SAN J O A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name. Owner Name. Date: <br /> grS SOUZWUC-.1H OJERfl_A ZAPAiA 6I/3o/Zg <br /> .CFO Physical Address. CFO city. CFO Zip. <br /> 176193 6AWLLA- PLAc..e L_ATB2oP RS330 <br /> Website(it applicable): Telephone: <br /> las0-303-LM O <br /> 1. Categories: <br /> ❑ Class A (Direct Sales Only) $186 'Class B' (Direct& Indirect Sales)$312 <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-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:%QUiLpOu&i H RILE Aro�SOurtnull F0GAL;_t4 C L'lAY LI c. PArcn LO0.16q <br /> C1AflLIL3 01EDD AIL 3ALAPSWO L3 Ari 3ALAJ C Na] , 01-1Ve Z_!sEMAal L OIL%GO <br /> F.ns�ALIID PL^1A4© Oil G1AlbAPIA © OU�o hit <br /> r Cnu ouvf, <br /> 4. Product Labeling: <br /> Attach one label 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 /> p�Ety 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 handier certdlCation 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 209 468.34201 F 209 464-0138 1 www sjgov org/ehd <br />