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Environmental Health Department <br />Website (If applicable):925-621-9492 <br /> ‘Class B" (Direct & Indirect Sales) S486 <br />2. Prohibited Items: <br />3. Products: <br />Food List:Cupcakes,Cakes <br />'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results ) <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />Environmental Health Department <br />8. Owner's Statement: <br />Supriya Santhilal <br />Supriya Santhilal <br />05/1/2026 <br />Print Name Date <br />CFO City: <br />Mountain House <br />Telephone: <br />7. 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. However, all 'Class A- and <br />'Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may not be <br />delivered via the United States Postal Service. UPS. FedEx, or using any other indirect delivery method as <br />deliveries are regulated by. and subject to. CDPH registration and state and federal requirements <br />I. r"J ..., agree to grant access to the local health department to <br />conduct an inspection of my cottage food operation (mark one) <br />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 />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 />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br /> "Class B": For regular annual facility inspections <br />and in the event of a consumer complaint or <br />food-borne illness <br />CFO Zip <br />95391 <br />CFO Business Name <br />_______Supri_bakes <br />CFO Physical Address <br />472, W San Juan Ct <br />SAN JOAQUIN <br />COUNTY <br />SAN JOAQUIN <br />COUNTY------ <br />1. Categories: <br />0 -Class A" (Direct Sales Only) SI86 <br />S "Class A”: In the event of a consumer <br />complaint or reported food-borne illness <br />I.Supriya Santhilal agree to notify the San Joaquin County Environmental <br />Health Department prior to modifying my food list, type of operation, and/or method of selling, distnbuting. or <br />otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold, <br />consigned, or given away <br />Owner's Signa/ure IJ <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 />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 />5. Water Source: <br />Please check what type of water source is being used al the CFO: <br />CX City Water Private Well' <br />D?!?1/2026Owner Name <br />Supriya Santhilal