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r s Signature
<br />SAUD/MIN
<br />COUNTY
<br />Environmental Health Department
<br />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. However, all "Class A" and
<br />"Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may not be
<br />delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method as
<br />deliveries are regulated by, and subject to, CDPH registration and state and federal requirements.
<br />Owner's Statement:
<br />, agree to grant access to the local health department to
<br />conduct an inspection of my cottage food operation (mark one)
<br />"Class A": In the event of a consumer
<br /> d "Class B": For regular annual facility inspections
<br />complaint or reported food-borne illness and in the event of a consumer complaint or
<br />food-borne illness
<br />I\AcInsell-e •f41-4\ , agree to notify the San Joaquin County Environmental
<br />Health Department prior to modifying my food list, type of operation, and/or method of selling, distributing, or
<br />otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold,
<br />consigned, or given away.
<br />I, Mi(hette1<ultik_
<br />Midatol -u Fau •g5
<br />Print Name Date
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<br />(AN\ 1\10N ROLL BREAD
<br />MADE IN A HOME KITCHEN
<br />PERMIT #13 10028981 /
<br />ISSUED IN SAN JOAQUIN COUNTY /
<br />BLESSED OLUTENLESS BAKERY'
<br />LOCKEFORO, CA 95237 /
<br />(209) 503-0884
<br />INGREDIENIS: GLUTEN FREE BAKING FLOUR (RICE
<br />FLOUR, WHOLE GRAIN BROWN RICE FLOUR, POTATO
<br />STARCH, WHOLE GRAIN SORGHUM FLOUR, TAPIOCA
<br />FLOUR, XANTHIN GUM), SUGAR, POWDERED SUGAR,
<br />BUTTER, EGGS, VEGETABLE OIL(SOYBEAN OIL),
<br />MILK,VANILLA EXTRACT, CINNAMON, BAKING
<br />POWDER. SALT
<br />CONTAINS: EGGS. MILK, SOY
<br />NET WT.
<br />HOCOLATE CHIP
<br />COOKIES
<br />MADE IN A HOME KITCHEN
<br />PERMIT #PT0028981
<br />ISSUED IN SAN JOAQUIN COUNTY
<br />BLESSED CLUTENLESS BAKERY
<br />LOCKE FORD, CA 95237
<br />(209) 503-0884
<br />INGREDIENTS: GLUTEN FREE BAKING
<br />FLOUR (RICE FLOUR, WHOLE GRAIN
<br />BROWN RICE FLOUR, POTATO STARCH,
<br />WHOLE GRAIN SORGHUM FLOUR, TAPIOCA
<br />FLOUR, XANTHIN GUM), CHOCOLATE CHIPS
<br />(SUGAR, CHOCOLATE LIQUEUR, COCOA
<br />BUTTER, SOY LECITHIN. NATURAL
<br />FLAVORS). SUGAR, BUTTER(MILK. SALT),
<br />EGGS, MILK, VANILLA EXTRACT, BAKING
<br />SODA,BAKING POWDER, SALT
<br />CONTAINS: EGGS, MILK, SOY
<br />NET WT.
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