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Environmental Health Department <br />Date: <br />■ZQG <br /> 'Class B° (Direct & Indirect Sales) $486 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />SANJOAOUIN <br />-----COUNTY------ <br />Greatness grows here. <br />cm »frup (tern •frvp. <br />CFO Zip: <br />1 <br />1. Categories: <br />CO “Class A' (Direct Safes Only) $186 <br />*: Made in a Home Kitehen <br />P*rn>H»OM*K -------! - -rnntf fur <br />AotorMH VtaM to KM OnfaMm <br />M4 OrW* Um Udi. ca <br />WJMWI tapr UMto* leytotaft: AO'^ur^oM floor OMomhod «bM flour, oudted borior flour <br />ntotto. rvducod Iron. nononltrrt*. rfteflrvfn. foU odd), bottor (aft. ruta-d fioror). <br />- coafrnon'i'OMiprtesar. cormtonti). ogj. ortAcM ntAo otom^ *«. tMtos powtor. <br />Contotor tdioA. *95, a* Not Vft. KU u. flrKeflg) <br />- Ulng tngndtonta: coa^dtonm'oogor (ougor. eocnotardi). tooctogm powdor. <br />vtt. mndto rrtrod). orttfidal nafflo wtroct. Motor, uhito food wtortag. <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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />3. Products: <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 />Food List <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />City Water Private Well* <br />*lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />2. Prohibited Items: Initial If you agree to abide by the following: /lM/ <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-bome illness. <br />CFO Physical Address: CFO City: <br />Loch <br />Website (If applicable): Telephone: