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SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY— <br />Greatness grows here <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name:, Date: <br />(2, /-/-/z/ set Lek 41-30 -Z013 <br />CFO Physical Address: CFO pity: CFO Zip: <br />179'7 4/ .Tre-Mee.04./ Locke4e d 3757 <br />Website (If applicable): Telephone: <br />Z°9 — “3 -5 7 75- <br />Categories: <br />"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: <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: <br />BAK.&61 5 - <br />5p1th 6 CO se- Ai 5 hc rcJ, <br /> <br />„Silll r ) 5 o 1-4e 11 IA / <br /> <br />Cherie Segler <br />17971 N Tretheway Rd <br />Lockeford, Ca 95237 <br />Text 209-663-5775 <br />Ingredients: Unbleached flour(wheat flour, niacin,reduced iron, <br />thiamine, mononitrate, riboflavin, and folic acid), Fruit, Sugar, <br />Vegetable shortening, Cornstarch, Salt, Cinnamon, Nutmeg <br />Contains: Wheat <br />Made In A Home Kitchen <br />Permit #PT0025226 <br />Issued In San Joaquin County <br /> <br />Product Labeling: <br />Attach one label to this form for one of your CF <br />made). <br /> <br />Cfien'e's Pies <br /> <br />Water Source: <br />Please check what type of water source is being uu t WC <br />El City Water x/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 />lierc_kf-\ er1 /4 jo\.\--kro. <br />Net Wt 2.5Ibs (40.0 oz