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SQNAMU IN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />Ram Cook.\e C.O. ndYlGna MY--hheZ Ilzs�� <br />CFO Physical Address: CFO City: CFO zip: <br />2325 otegon Five gt[)CJ to <br />Website (If applicable): Telephone. <br />adriScaoV-\fco C� "a,l .cow, <br />1. Categories: <br />Q "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: f& <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: r,)JW , ONA(a\41rc alnep, a\YnWv <br />&lkt� gao65 : S119cr Ct&-t2S \r yuV to,.s -NA'46Ns ,V-W\k , lennn,c4wcol�t�e,�n a. <br />gt4 e cx Urn -lbs mq : NiNss rw\h:Vg 60obr crew "rA&, . wl pu��urt lei �95�J„Ak� <br />Teak \CIY\q : YouoVk-61" -It ae _Ya}e- SNAOMY C,hY;4A <br />10-4 khu�S voY_\_0 S -p Q ey< _ ap��e ct <br />Cjk.t (J%V4L : VOQVt4\\c,, Q\MbrAj CV1bco\a}c, medvelvt.1trr,un, Gnncrnw,ecArip}, orw I biSoff <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 />kI 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 />