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SANPAIWN <br />cRECEIVECt <br />Greatiftt Str2164rt <br />Environmental Health Department <br />-C.) <br />177-----Pi a---tci 13 <br />AGE FOOD OPERATIONS (CFO) <br />RECISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />DEBR/E 5 %zE /WS 5WEE75 DEBB i c_Pcke Tait/ <br />CFO Physical Address: CFO City: <br />/030 ge)Yee_gie VLA2A/ .777/4d4/ <br />CFO Zip: <br />9 5 374: <br /> <br />Website (If applicable): Telephone: <br />Sk0 -53*&—Z5L+S <br />Categories: <br />"Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />2. 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 Sili of all products you are preparing. If preparing jams, jellies, or fruit butters inolude a list of <br />ingredients (attach separate page if needed). <br />Food List. &30(:-Ay" cocAc\ )25 c_x \(--) <br />b () 0-06k ki2./ Rak- c,‘noec)ct-k-e, 9-7-ombGi 0,u poa\,--esi <br />eSI ACX1A" crako_ V7o-t- .vrA" CVNOCJOAC <br />u..3r1 a k- Is <br />c_Ineico‘ak-e__ <br />Product Labeling: F14 <br /> <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 />IZ City Water LI 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 />c\ebb..,Q_c_.c.i,--\-\ :6coc.r3. <br />fbUr poi ct <br />CC* (NO (qD-