|
SAN.,10AOUIN
<br />
<br />Environmental Health Department
<br />COUNTY
<br />Delivery Limitation: Initial if you agree to abide by the following.
<br />I understand that I may accept orders and payments via the internet, mail or phone. However, all "Class A" and
<br />"Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may not be
<br />delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method as
<br />deliveries are regulated by, and subject to, CDPH registration and state and federal requirements.
<br />Owner's Statement:
<br />1 , %Mc cine-V1 ,agree to grant access to the local health department to
<br />conduct an inspection of my cottage food operation (mark one)
<br />111"Class A": In the event of a consumer "Class B": For regular annual facility inspections
<br />complaint or reported food-borne illness and in the event of a consumer complaint or
<br />food-borne illness
<br />fackivel_ke, ,agree to notify the San Joaquin County Environmental
<br />Health Department prior to modifying my food list, type of operation, and/or method of selling, distributing, or
<br />otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold,
<br />consigned, or given away.
<br />VFN,a(Ailit\-CUrc
<br />me Date w -r' Signature
<br />BANANA BREA I)
<br />BLITEBERR) CRUMBLE
<br />Al)E IN H 0 NI E I 'II: E N
<br />R NI I I'Im.)2898I MADE IN A HOME KITCHEN
<br />
<br />ISS1HE:1) IN S,\N 10 :\QUIN couvry PERMIT #PT0028981
<br />ISSUED IN SAN JOAQUIN COUNTY
<br />BLEssFu (at .TENLEss BAKE IRV
<br />LOLt.:I;()RI), (]:\ 9;237
<br />(20) ro)
<br />B.NI\IN6 HMI R (RICE OUR.
<br />(,RAIN Blum\ llicF, ['1011 fl. poTAT0
<br />STARCH W1-1()1,1-: Sw;(;111.\I
<br />FLOUR. TAPIOCA FLOUR, V\NTIIIN
<br />(iLINI), BROWN CANE
<br />N101,.\SES), SALT),
<br />SOUR CREAM, VANILLA 1-:\TR
<br />LINN.110N. IL\ICIN(; S01).1. SALT
<br />CONT.1iNS: IT(,;(.;S, MILK. SOY
<br />BLESSED GLUTEN LESS BAKERY
<br />LOCKEFORD, CA 95237
<br />(209) 503-0884
<br />INGREDIENTS: GLUTEN FREE BAKING
<br />FLOUR (RICE FLOUR, WHOLE GRAIN
<br />BROWN RICE FLOUR, POTATO
<br />STARCH, WHOLE GRAIN SORGHUM
<br />FLOUR, TAPIOCA FLOUR, XANTHIN
<br />GUM), SUGAR, BLUEBERRIES, EGGS.
<br />SOYBEAN OIL, MILK, BUTTER, PURE
<br />VANILLA EXTRACT, BAKING POWDER,
<br />SALT
<br />CONTAINS: EGGS, MILK, SOY
<br />N I, I WT. NET WT.
|