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El Nitrite Test (every 3 years*): <br /> <br />”Additional information may be required if food Is prepared from a home w 1.1 :)iivate water supply - check with tope jurisdiction. <br />Food Processor Course: Initial if you agree to a bide by the following: <br />Within 3 months of being approved to operate by the Environmental Health Department, please <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdph.ca.qov proqramsiPaqesftdbCottaqe Food.aspx <br />Employee: Initial if you agree to abide by the following: <br />I understand that I may not have more than one full-time equivalent cottage food employee, not <br />including a family member or household member of the cottage food operator, working within the <br />registered or permitted area of a private home where the cottage food operator resides and where <br />cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to <br />constimers <br /> <br />10.Delivery Limitation: Initial if you agree to abide by the following: <br />I understand that I may accept orders and payments via the Internet, mail or phone. Direct and <br />Indirect sales may be fulfilled in person, via mail delivery, or using any other third-party delivery <br />service throughout the state of California only. <br />11. Owner's Statement: <br />Wt.t Ii A -z-c4 ,d , agree to grant access to the local health <br />departpent tO conduct an inspection of my cottage food operation (mark one) <br />'Class A": In the event of a consumer E "Class B": For regular annual facility <br />complaint or reported food-borne illness inspections and in the event of a consumer <br />complaint or food-borne <br />W ait(' A Z--a ,agree to notify the San Joaquin County <br />Environmental Health Department prior to modifying my food list type of operation, and/or method <br />of selling, distributing, or otherwise providing my CFO products to the consumer or retailers, <br />regardless o wh ther the product is sold, consigned, or given away. <br />?A/CA 42-0. <br /> 4.2 Lalc, 3 <br /> <br />Owner's Signature Pint Name Date <br />EHD 18-27 6/2912023 5 C.00 REG/PERMITTING FORM