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smunum <br />Environmental Health Department <br />—COUNTY <br />1..c); Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />/4 1; c3 Cl/k001 ttieS <br />CFO Physical Address: <br />C( 6k1j,4 C4, <br /> <br />Owner Name:. <br />ce hn506 <br />CFO City: <br />avii-ec4 <br /> <br />Date: <br />P-(4-14 <br />CFO Zip: <br />qc-3'17 <br /> <br />Website (If applicable): <br />/ <br />Telephone: <br />g5 Cf 0 <br /> <br />1. Categories: <br />XI "Class A" (Direct Sales Only) $186 Lii "Class B" (Direct & Indirect Sales) $486 <br />Initial if you agree to abide by the following: Or <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 />3. 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 />Cara me15g4.61,(1e.. ior0Wille5 COO/6i e-5 114 4rSiolUthmkS j J <br />C ( $ ec (('‘) Cerse1 ;r1 3r-eAvv-e,,^e,o( cl-ef-apv,k)) %Ada Cz-ne-5/ teg-t-e5- <br />C,11 0 c_ock.i.e_ -co-yet-e.t9t i(-z,e1 Car& met.5 gkid c..6016;_c ) rvt (-S. ik l'uvz.,t \45 <br />k,T <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 />rgl City Water CI 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 <br />2. Prohibited Items: