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"1117‘ <br />SAN JOAQUIN <br />—COUNTY-- <br />PC-OS k)Ss <br />Environmental Health Department <br />FrROC2.09.8 <br />,4\''r Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br /> <br />Owner Name: <br />MtC)Mk IA MO— <br />CFO City: <br />141-D-f <br /> <br />Date: *2] al <br />CFO Zip: <br />Cf 3 -11 <br /> <br />.4kLIAts <br /> <br />CFO Physical Address: <br />INSOO 01 <br /> <br />Website (If applicable): <br />.-r4k1A-scooHCS „CoM <br />Telephone: , <br />(510) I'VN9920 <br />Categories: <br />CI "Class A" (Direct Sales Only) $186 Ej "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: <br />NOY-IFS' Ctocoaa uki? nikur (krucoulnCth , CLEO RAO <br />SiW(Ac419001)(/‘ VOlki`O utocoilylt utO? tooko, c9-eRm i 7Ria1Lr p24-1-0--ft}-4q1 <br />VI\ ttftttAA-K ft,94 "11 TOffFf NV) MO, WW1 RtkAok10, 1\01-01t ktkrahOi <br /> <br />t\AWR-u\ wit-k-IT (*co Aff-Ckki tocoistkr Viktop-m WfNalc4-qu1, <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 />City Water Private Well* <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