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E] 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: <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 websde www.cdph.ca.qov/procirams/Paqes/fdbCottacieFood.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: <br /> <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, yke L. wrIKA-- , agree to grant access to the local health <br />departmgnt to conduct an inspettion of my cottage food operation (mark one) <br />1=I"Class A": In the event of a consumer <br />complaint or reported food-borne illness <br />',"Class B": For regular annual facility <br />inspections and in the event of a consumer <br />complaint or food-borne <br />1, (.1.kicl-ke L. Writtl,V , agree to notify the San Joaquin County <br />EnvironMental Health DeOrtment 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 />LI <br />1A.) <br />Owne Signatur <br /> <br />KY vIci-te. W6 0\ht <br />Print Name <br /> <br />It k 2 <br />Date <br /> <br />EHD 16-27 6(2912023 5 CFO REG/PERMITTING FORM