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El Nitrite Test (every 3 years*): <br />**Additional information may be required if food is prepared from a home with a private water supply — check with local jurisdiction. <br />Food Processor Course: Initial if you agree to abide by the following: (ik.) ii <br />Within 3 months of being approved to operate by the Environmental Health Department, please <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdph.ca.gov/procirams/Pacies/fdbCottacleFood.aspx <br />Employee: Initial if you agree to abide by the following: 1,) <br />I understand that I may not have more than one full-time equivalent cottage food employee, not <br />including a family member or household member of the cottage food operator, working within the <br />registered or permitted area of a private home where the cottage food operator resides and where <br />cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to <br />consumers. <br />Delivery Limitation: Initial if you agree to abide by the following: (,0 <br />I understand that I may accept orders and payments via the internet, mail or phone. Direct and <br />Indirect sales may be fulfilled in person, via mail delivery, or using any other third-party delivery <br />service throughout the state of California only. <br />Owner's Statement: <br />I, t -(34\ , agree to grant access to the local health <br />department to conduct an inspection of my cottage food operation (mark one) <br />LI "Class A": In the event of a consumer <br /> n "Class B": For regular annual facility <br />complaint or reported food-borne illness inspections and in the event of a consumer <br />complaint or food-borne <br />I, L3 :A0 .,0 ,agree to notify the San Joaquin County <br />Environmental Health Departnfent prior to modifying my food list, type of operation, and/or method <br />of selling, distributing, or otherwise providing my CFO products to the consumer or retailers, <br />regardless of whether the product is sold, consigned, or given away. <br /> <br />AP( ) A._ yio \ r_c. <br />Owner's-Signature <br /> <br />\-) 0 r_c., 7 • <br />Print Na e Date <br /> <br />EHD 16-27 6/29/2023 5 CFO REG/PERMITTING FORM