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� 1 f SAN JOAQUIN *� Environmental Healt epartment COUNTY EI v�,D Greotness grows here kNV APR �? ?D COTTAGE FOOD OPERATIO�:� !k°N�"INP ?4 �-- –, U �G REGISTRATION/PERMITTING RENEWAL FORM �J�p4RP44L f1tAC-t1l CFO Business Name: Owner Name: Date: CFO Physical Address: CFO City: CFO Zip: 83� fed mY-A Or )NI A1�V_1 34 Website(If applicable): Telephone. 1. Categories: ❑ "Class A" (Direct Sales Only) $186 "Class B" (Direct& Indirect Sales) $486 2. Prohibited Items: Initial if you agree to abide by the following: L-�2— Fccds ccn+.wining 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. 3. 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: 1rY�fif) !'�� 1' T �Lt C1r;19J Cct rCOT , ea-J Choi Ch,,D >3�� pct nci n� S0')Ca 00�I I e�r20-d oBaru 4. 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). 5. Water Source: Please check what type of water source is being used at the CFO: City Water ❑ Private Well* *If a private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) 6. 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com Kos"A u� �I S