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Date: <br />2oq-L|r7H?,q'7 <br /> “Class B* (Direct & Indirect Sales) $250 <br />h>jk <br />EHD 16-29 6/29/2015 1 CFO REG/PERMmiNG RENEWAL FORM <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />T*tephon»: (209) 468-3420 Fax: (209) 464-0138 Wab: www.sjcehd.com <br />1. Categories: <br />53 “Class A" (Direct Sales Only) $125 <br />5. Water Source: <br />Please check what type of water source Is being used at the CFO: <br />City Water Private Well* <br />‘If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />OwnerName. <br />nckicin/i WMrrinp.? <br />CFO City. <br />Lodi <br />Telephone <br />CFO Zip <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. <br />Only foods that are defined as “non-potentially hazardous” are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-borne illness. <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 <br />product is made). <br />CFQ Business Name. <br />Adv' vs (boVAg Cja <br />CFO Physical Address. <br />braeflurn Ln. <br />Website (If applicable) <br /> Wri XN - Qdr . <br />3. Products: <br />Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list <br />of ingredients (attach separate page if needed). <br />Food List. g-Vc-el ; <br />-----i C/Vb|k;