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Environmental Health Department <br />20^ <br />□"Class B” (Direct & Indirect Sales) $486 <br />2. Prohibited Items: <br />3. Products: <br />Food List: <br />4. Product Labeling: <br />Cfierw's'Pies <br />5. Water Source: <br />*lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />6. Food Processor Course: <br />Initial if you agree to abide by the following: Cx-J <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 />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 />Attach two labels to this form for two of you <br />made). <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 />Please check what type of water source is being used at the CFO: <br />□ City Water ^Private Well* <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjcehd.com <br />SAN JOAQUIN <br />------COUNTY------ <br />Greotncss grows here. <br />1. Categories: <br />"Class A” (Direct Sales Only) $186 <br />Date: <br />9-30 <br />CFO Zip: <br />9S237 <br />r~, ,6 h o r 4 g ri i AJcyPie-S <br />Cherie Segler <br />17971 N Tretheway Rd <br />Lockeford, Ca 95237 <br />Text 209-663-5775 <br />Ingredients: Unbleached flour(wheat flour, niacin,reduced iron, <br />thiamine, mononitrate, riboflavin, and folic acid), Fruit, Sugar, <br />Vegetable shortening, Cornstarch. Salt. Cinnamon. Nutmeg <br />Contains: Wheat <br />Made In A Home Kitchen <br />Permit #PT0025226 <br />Issued In San Joaquin County <br />Net Wt 2.5lbs (40.0 oz <br />Co taj ____________ <br />CFO Business Name: < Owner Name: <br />C-H^iri€:5 pies- StCLE/Z <br />CFO Physical Address: CFO City: <br />I mil TreP-heijiny A'd <br />Website (If applicable): Telephone: