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'Class B' (Direct & Indirect Sales) $312 <br />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 />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 VAv.4 411.A-S Coo K•ts hiJ (A/1-1-s <br />7. Delivery Limitation' Initial If you agree to abide by the following: J/6 <br />I understand that I may accept orders and payments vie the intermit, mad or phone. However, ail 'Class A' and <br />13" CFO products must be delivered glrectiv In person) to the customer. The CFO products may not be <br />delivered via the United States Postal Service. UPS, FedEx. or using any other indirect delivery method as <br />deliveries ere regulated by, and subject to. COPH registration and state and federal requirements <br />B. Owner's Statement: <br />, agree to grant access to the local health department to <br />conduct an Inspection of my cottage food bon (mark one) <br /> <br />0 "Class A": In the event of a consumer Ef "Class Er: For regular annual facility inspections <br /> <br />complaint or reported food-borne illness and in the event of a consumer complaint or <br />food-borne Illness <br />I, ACC#'641 tj agree to notify the San Joaquin County Environmental <br />Health Department prior to modifying my f d list, type of operation, and/or method of selling, distributing, Of <br />otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold. <br />consigned, or given away. <br />1. Categories: <br />0 'Class A' (Direct Sales Only)S186 <br />ci42,55-s i6jr.4.1 <br />Print Name Dale <br />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 />Ci City Water 0 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 95205J T 209 468-3420 I F 209 464-0138 www.$)gov.orgfehd <br />P e_ o 2 s <br />Environmental Health Department Environmental Health Department <br />lift 1 wrrOlts <br />SAN JOAQUIN <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />emitann 6R4i=v3 cIwner""mitssl c/v+ tuf.N Wy°1°. <br />cmir"roisi-L-14140 ter, -ry-te cic74-3:), <br />rsIsasew (cy'o 1113 w.b..m.s..o IA ssT(A4\