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SANIJOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY— <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Npme: Owner Name: k <br />d V-k S: <br />CFO Physical Address: CFO City: <br />zion. imAck.k6viDcZ <br />9C:531 -1 t. SC% (Al a (+WO -Mt& ( <br />Website (If applicable): Telephone: <br />SA-1 Credek_nei,c04-1 Liej ?--C CI 9 y to 2z_t <br />-U. Z62 q <br />1. Categories: <br />[X "Class A" (Direct Sales Only) $186 111 "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 />Food List: <br />,c)opS )--V-udcy-3 ) <br />, <br /> <br />-greAKon (3, e 4-1-1A VA-te <br />U S) -S'exciet G (\CUQc <br />( (Ice_ <br /> <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 El 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 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />it\ \e- e Cc.) ,yyNk_N-- k cA,‘Nin <br />cxr\d