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5 CH> Rl G.I'l RMI11ING I OHMI HO 10-27 6/29/2023 <br />U-lo-3-024? <br />Date <br /> “Class B”: For regular annual facility <br />inspections and in the event of a consumer <br />complaint or food-borne <br />“Class A”: In the event of a consumer <br />complaint or reported food-borne illness <br />(~] Nitrite lest (every 3 years*) <br />••Addrfionat information may b® required If ’ood Is prepared from a home with a private wafer atippty -chedt wrfh focal i”'-" <br />10. 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. Direct and <br />Indirect sales may be fulfilled in person, via mail delivery, or using any other th'rd-party delivery <br />service throughout the state of California only. <br />8. Food Processor Course: Initial if you agree to abide by the following <br />Within 3 months of being approved to operate by the Environmental Health Department please <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course <br />Foi more information see CDPH website yvww.cdph.ca gov/progranis/PaBCS/fdbCottPfleFoQd.aspx <br />9. Employee: Initial if you agree to abide by the following: <br />I understand that I may not have more than one full-time equivalent cottage food employee not <br />including a family member or household member of the cottage food operator, working within the <br />registered or permitted area of a private home where the cottage food operator resides and where <br />cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to <br />consumers <br />11. Owner’s Statement: <br />I,, agree to grant access to the local health <br />department to conduct an inspection of my cottage food operation (mark one) <br />i. I rrritv 67^2^11 ____, agree to notify the San Joaquin County <br />Environmental Health Department prior to modifying my food list, type of operation, and/or method <br />of selling, distributing^otherwise providing my CFO products to the consumer or retailers, <br />regardless of^vK^lerth^ product is sold, consigned, or given away <br /> <br />JX Owne^sjiig^ature <br />km <2- <br />Print Name 1