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6 EHD 16-27 6/29/2023 5 CFO REG/PERMITTING FORM Date Nitrite Test (every 3 years*): " "Additional information may be required if food is prepared from a home with Print Name I, department to conduct ’‘Class B”: For regular annual facility inspections and in the event of a consumer complaint or food-borne Cj “Class A”: In the event of a consumer complaint or reported food-borne illness a private water supply - check with local jurisdiction. ^-^7---------—------ --------——______agree to notify the San Joaquin County Environmental Health Department prior to modifying my food list, type of operation, and/or method of selling, distributing, or otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold, consigned, or given away. 11. Owner’s Statement: _ agree to grant access to the local health ct an inspection of my cottage food operation (mark one) "XOwner’s Signature 1 °-P.eliverY Limitation: initial if you agree to abide by the following: /■.; - I understand that I may accept orders and payments via the internet, mail or phone. Direct and Indirect sales may be fulfilled in person, via mail delivery, or using any other third-party delivery service throughout the state of California only. 9. Employee: Initial if you aaree to abide b th f n I understand that I may not have more than one full-time equivalent cottage food employee not including a family member or household member of the cottage food operator, working within the registered or permitted area of a private home where the cottage food operator resides and where cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to consumers. 8. Food Processor Course: Initial if you agree to abide by the following- For more information see CDPH website www.cdph.ca.qov/proqrams/Paqes/fdbCottageFood.aspx