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00 Z-j- 2 <br /> SAN 10AOUIN Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Nerve Owner Nems <br /> �cl Dmacs iYt-YJ <br /> CFO Physeal Address -- CFO City CFO Zip <br /> �aCa GS3� <br /> Websde(if appimble) Telephone J <br /> �vt� rviGckS- maC�. <br /> 1. Categories: <br /> ❑ 'Class A'(Direct Sales Only)$186 ,� "Class B"(Direct 8 Indirect Sales)5312 <br /> 2. Prohibited Items: Initial if you agree to abide by the following:F <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLO ED 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 h r-� CXId I�Gllpn Mir"(CfCOS t �W)S� YY12CtV)C�tJ-Q <br /> V-)U Ne� C PCn'1 C(C4QChP <br /> 4. Product Labeling: <br /> Attach one label to this form for one of your CFO products(only one label is required if only one product is <br /> made) <br /> 6. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> v6.J 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 s)gov orglEHD <br />