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SAN JOAQUIN <br />□ "Class B" (Direct & Indirect Sales) $486 <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www sjcehd com <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATIOWPERMITTINO RENEWAL FORM <br />water source is being used at the CFO: <br />□ Private Well* <br />Date <br />CFO Zip <br />2/ <br />Environmental Health Department <br />1. Categories: <br />Class A" (Direct Sales Only) $186 <br />6. 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 />4. 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 />5. Water Source: <br />Please check what type <br />"^T'City Water <br />‘If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />3. 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: <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 />KJ. <br />Cl O Business Name <br />JXlU.j'Vv 'tb « A I <br />CFO Physical Address ~~ <br />Website (If applicable) <br />•"C Aj VI c< to_________ <br />S g (A £ c.Ajc c (a ____________ <br />d/tot A <br /><c cleccjU <br />C U <br />Owne^Name^ <br />k 'L,« i-Xcivuc- f <br />CH) City <br />_ <br />Telephone <br />7oq. -1(