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S N JOAQUIN COUNTY-- Gre e.s! ,'VOwS hf ,'(` Environmental Health Department COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING RENEWAL FORM CFO Business Name: Owner Name:, Date: f 1 , e_JalUk‘rd'l C-Otq W -eCS OJA € rj ) hnLI C-ir)% CFO Physical Address. CFO City: CFO Zip: --) c-0 ( 1 -4.0tvle\-e_ckci. --i---, VI 1 ar-d--t c_67( 1 9 SSG, Website (If applicable): Telephone: LAAAAA-7. CI 1/4-10CC_VI C—rotz) b t •e_ r- b, C,0 y-v-) .(q09 -410 Categories: I "Class A" (Direct Sales Only) $186 L. E "Class B" (Direct & Indirect Sales) $486 2. Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food-borne illness. Products: Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list of ingredients (attach separate page if needed). Food List: S e_ s Product Labeling: Attach two labels to this form for two of your CFO products (only one label is required if only one product is made). Water Source: Please check what type of water source is being used at the CFO: City Water 111 Private Well* *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) Food Processor Course: Attach food handler certification for owner and each individual that were not submitted with initial application (including family members and/or employees). 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com WA) 54101q