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<br />LI Nitrite Test (every 3 years') <br /> <br />—Additional information may he 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 beina 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/PaqesfidbCottacieF000 asc7 <br />Employee: Initial if you agree to abide by the following: L, <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 />10.Delivery Limitation: Initial if you agree to abide by the following: <br />I understand that! 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 />11. Owner's Statement: <br />i. Pu_r,kj <br /> <br />fu) , agree to grant access to the local health <br />aepartment to conduct an in ection of my cottage food operation (mark one) <br />"Class A": In the event of a consumer <br />complaint or reported food-borne illness <br />LI "Class B": For regular annual facility <br />inspections and in the event of a consumer <br />complaint or food-borne <br />daree to notify the San Joaquin County <br />Environmental Health Deriirtment 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 retailer- <br />regardless of whether the product is sold, consignee, or elven awe. <br />ic.r2L (0,9oi <br /> <br />tuJc,u( I <br />Date <br /> <br />..wner's Sianature Print Name <br /> <br />EHD 16-276/29/2023 <br /> 5 CFO REG)PERMiTTING FORM