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SAN JOAQUIN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name Date <br />I S. 6A/` Ne6kA ')WAJt- %1047.‘a,3 <br />CFO Physical Addis's CFO Zip <br />q 5- 55 <br />Websde of applicable) Telephone <br />WV% VI- VI' riz -q 13 <br />te ories: <br />Class A' (Direct Sales Only) $186 0 'Class B (Direct 8. 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 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 Cr ct s tit 1441 L 5 -kF <br />CAT c cou,c math vo <br />Product Labeling: <br />Attach one label to this form for two of your CFO products (only one label is required if only ore product is <br />made) <br />Water Source: <br />e check what type of water source is being used at the CFO <br />City Water LI Private Welr <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 ) Stockton, Calito!nia 95205 I T 209 468 3420 F 209 464-0138 I www sigov or g ehd <br />CFO City <br />_Ly2205a4v,t,ti Lamm) r