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PR 0 5' Li 614 :12 <br />SAN JOAJUIN <br />C L.1 N 1 <br />Envronmeni. Hea1th Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name. <br /> <br />3firtknrAIS GC/Mt 0rectfOrts Ian mAnalA <br />CFO Physical Address: CFO City: <br /> vVIC6V\cte KA. Es coukoo <br />Date <br /> P-g <br />CEO Zip: Zip: <br />q5312-0 <br />Website (If applicable): Telephone: <br />2M_MeAP_CD_OtLe_Mich0715 q)f\A U2Vt -1(Sti <br />Categories: <br />Yr "Class A" (Direct Sales Only) $186 [I1 "Class B" (Direct & Indirect Sales) $486 <br />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 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: SAV4CALADIA. S '192__AZ4CMICACI___SikCjAr tA/t vcivi jftc <br />gctit+Aotv-oi 9 rOW &t, c l _q_qs • <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 />111 City Water Miprivate 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 1 Stockton, California 95205 1 1 209 468-3420 I F 209 464-0138 I wvvw.sjcehd.com