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p fLo \a 1 /4,i kit <br />SAN JOAQUIN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name Date <br />ke4kCA‘ Au A 0 C.1124)2,3 <br />CFO Zip <br />CfS 55L) <br />Websrte (If applicable) <br />St - 10-kitr LOA i.ka <br />1. te ories: <br />0 "Class 8" (Direct & Indirect Sales) $312 "Class K (Direct Sales Only) $186 <br />Initial if you agree to abide by the following: /V\ • Pr. <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 bactenal 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 prepanng jams, jellies, or fruit butters include a list of <br />ingredients (attach separate page if needed) <br />Food List C VLS .1 AC I tdd,C. "TatA/1 5‘-'104r i 51( Ica- frifiA-. <br />(AT (1,0.1,(5\ trY1 (113/6 WA( <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 />Water Source: <br />Pie e check what type of water source is being used at the CFO <br />City Water D Private Well* <br />if a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results ) <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov org/ehd <br />CFO Physical Address <br />Ludt s <br />CFO City <br />Telkione <br />1 _VC- riz q -i 31 <br />2. Prohibited Items: