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SAN JOAQUIN <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO�f�in s Name: 1 ame: n Date: <br />l `��t'S LJ In QVl fl ( Y c <br />CFO Physical Address: CFO City FO Zip: <br />WebsiteIf applicable): Telephone: �'` <br />�� b u►� �l5 q -- <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 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 pre- MADE IN A HOME KITCHEN <br />ingredients (attach separate page if needed). Permbm"1' wows <br />Ivoed m Camn: ben 3a'. <br />Food List: Creative Cookies by Diava <br />7 W Alyca Ct Tray Ca 953W <br />(�� O �\� lopredkms-Fmchal wbkacbed utcs Ml -"M L(lmrt 111.rWaed um. lh.nin, mavu nhrne, rilmfhaiu. <br />folic Wi "kit WtkY Ilene, mW. Wo pa>lem M arca a ia:)a0, urga IM, bmmi sugar, uh, baking p %vdn. <br />1 �� pme aauilh¢vtecUamWa Mm exuaakzwuater. ekoho4l5•..1 <br />� \\l, kin81nem1ients: PowUcd>apMwgm,mm>utchl timer, meruigue ry,udetlm,WifiW fend catch. eggwhi)e>..v�r. <br />D -- gum arabic.sdimn ahvnium solfaUc. ClUi acd.�moftucv.smiillim mm svrupmm sY�+Raah, annillal iutuml <br />anificullk>aeing food dyc <br />Al.abl I1 <br />\Itle m e ticbis egR \OT T.0 nut free <br />U Wr be8� Oi9g1 <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). L <br />5. Water Source: <br />Please check what type of water source is being used at the CFO:_Q� 4 1 1 n:� <br />❑ 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />