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c)(LcDS'I`a ()ZS- <br />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: <br /> <br />Owner Name: <br />\f LC41 0 S <br />CFO City: <br />rciN <br /> <br />Date: <br />1 211 '2.9.) <br />CFO Zip: <br /> <br />c?,AveJ 14FAI6 <br /> <br />CFO Physical Address: <br />1(1q ott <br />VVebsite (If applicable): <br /> <br />Telephone: (4.05) <br /> <br />Categories: <br />414, "Class A" (Direct Sales Only) $186 <br /> "Class B" (Direct & Indirect Sales) $486 <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: \ kAy. ‘a , mix 3iAim mai 00,01 <br />WW1 M t Ned N6011', i---‘01:(k. v-vqk-e_c <br />RECEIVED <br />JAN 0 4 2024 <br />ENVIRONNIENTAL HEALTH. <br />DEPARTMENT <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 />rA City Water E Private Well* <br />1--Ckj0.5 <br />ey b-- - <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.sjcehd.c,om <br />bO\V--"RA ‘0 'CT\ 5—E• sai ty\c",\ • c---Q-or-N