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SA <br /> <br />JOAQUIN <br /> Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name • Owner Namei Date <br />Sck_A-3_04u:v‘._,Seniclo <br />Date <br />O 06-11-2023 <br />CFO Physical Address. CFO City: CFO Zip. <br />Z. ?..'01er Ve..14 C,z Soc,\Qcov\ GA 61,52,oci <br />VVebsite (If applicable). Telephone. <br />Lki_s_-S3o -6119 <br />Categories: <br />2. -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: 31) <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 />SovraVdds, Utook C?, t‘c4) <br />Product Labeling: <br />Attach one label to this form for one 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 />15;' 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 209 468-3420 I F 209 464-0138 I www.sjgov.org/EHD