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“Class B" (Direct & Indirect Sales) $250 <br />KMH <br />Food List: <br />Dried Tea Blends <br />‘If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />CFO REG/PERMITTING RENEWAL FORM1EHD 16-29 6/29/2015 <br />CFO Business Name: <br />Blue Rose Bakery & Tea <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO City. <br />Lathrop, CA <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sicehd.com <br />Date: <br />7/21/26 <br />CFO Zip: <br />95330 <br />1. Categories: <br />R “Class A" (Direct Sales Only) $125 <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 />Cakes, Muffins, Pastries, Cookies, Sweet Rolls, Macarons, <br />Croissants, Scones, Turnovers, Sourdough Breads, Focaccia, <br />CFO Physical Address: <br />1007 Mariners Cv. <br />Website (If applicable): <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />(XJ City Water Private Well* <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 />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 />Owner Name: <br />Kaitlyn M. Homon <br />Telephone: <br />(209) 278-9652