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Made with Xodo PDF Reader and Editor <br />For more informalion see CDPH website www.cdph.ca.qov/proqrams/Pages/fdbCottaqeFood.aspx <br />9. Employee: <br />10. Delivery Limitation: <br />EHD 16-27 tZ73/2023 5 CFO REG/Pf RMITTING FORM <br />P3, “Class A”: In the event of a consumer <br />complaint or reported food-borne illness <br /> “Class B”: For regular annual facility <br />inspections and in the event of a consumer <br />complaint or food-borne <br />[ ] Nitrite Test (every 3 years*): <br /> <br />••ArtdHtonai information mny fvp required if food is prepared from a home with a privnio wstor supply chock with local jurisdiction <br />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 />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 third-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 />Date <br />11. Owner’s Statement: <br />I. ' U JoirftOT). agree to grant access to the local health <br />department toJonduct an inspection of my cottage food operation (mark one) <br />i. I , 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, or otherwise providing my CFO products to the consumer or retailers, <br />regardless of whether the product is sold, consigned, or given away. <br />Ownifs Signature Print Nafne