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, SAN JOAQUIN <br />— r OtJ N /- <br />Po 5b7- <br />Environmental Healtillpenc,nnt <br />FEB 2 7 2023 <br />COTTAGE FOOD OPERATIONS (CFO)N I I IN. ‘111zN .;\I Ir ikil.,,N1111,-1. LT1-1 <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name:,._N <br />it-St1 '-Rto3sely) ..toociker <br />CFO Physical Address: <br />L02 0.1.101'1 <br /> <br />Owner Name: Date: <br />P-601;tei ?eAC 2113/2 023 <br />CFO City: CFO Zip: <br />( rvi e L5 q377 <br />Telephone: <br />(20 ct) (1,2_7-0 5.7i <br /> <br />Website (If applicable): <br /> <br />--,sorp <br />Categories: <br />"Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $312 0(\c"-;\.1 <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: C ens,1 ,kes , 3cones, 1,04 c(ole M ;k, s, <br />cu rkps: d c, cck)k) <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 />Please check what type of water source is being used at the CFO: <br />El City Water 0 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 209 468-34201 F 209 464-0138 I www.sigov.org/ehd