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SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY-- <br />mY!..-siztow , <br />Ureatness r • <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: . <br />A z ) zck *`<-0,\r‘ kw\ ei‘ / 2 1 Z1 <br />CFO Physical Address: CFO City: CFO Zip: <br />5 V69 SC\NCIS-VeY. -.\,L,\C — <br /> <br /> <br />Lc 8 k 75Z YO <br />Website (If applicable): Telephone: <br />N/A .201 <br />Categories: <br />"Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: CA - <br /> <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 />SN're\r,e4L, <br />A\rri-er, •E' vb..10-1 plow: <br />coo it.e.rj <br />c-4‘ Ck <br />Cc-kl<t- <br />Food List:•wkoakt A. 01/4,0A, c c1 .v.v.sw-ms <br />-Vsceeft.C, vit\\ UN-N3s0,\\<• er ,f-'\eA ‘(61.15‘f 0A -S \c1/4.4 *lC:\ <br />oYy 0 SiCrle k5N\-te u-VAN. \\cAte,SAcIfe_ \ert *kyr \n, <br />CcANCe 'bseN \\\ 6Noc6kck. CeeS I Cal4 <br />ts.r c\Irsi \c,off xwi\e'q OR (Ivy c5vc-er6 "\\ \''`\‘`Y\ \szck\caa as C.114AYNn Sa 1+ rwkw,ea - <br />Product Labeling: <br />Attach two labels 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 />City Water 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! Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com