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p R_o<EN <br />SAN JO JOAQUIN Environmental -Health Department <br />U <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />ACELL.Busipess Nan e:' , <br />1.-401151-1 0.-1- Lv7 .;.)9,. In°, 0\04-PC. <br />CFO Physical Address: e _ <br />3 1,6 „Atari/47)0 A <br />' Website (If applicable): <br />Date: (: -3 <br />CFO Zip: . j It VAO1 <br />24 _151_1 <br />1. Categories: <br />"Class A" (Direct Sales Only) $186 1] "Class B" (Direct & Indirect Sales) $486 <br />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 />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 />g ity Water LI Private Well* E <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.com <br />2 Ar\ok(1-.0