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s 4 <br /> "ouip <br /> °P� SAKsJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> °aU �r Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CF0rusIness,Nann% Owner Name: Date: <br /> CFO�Pqy Address: CFO City: CFO Zip: <br /> -5y5`�.� <br /> Website(If applicable): Telephone: <br /> WGc�L.eJ . �r�-�{ <br /> 1. Categories: <br /> Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales)$310 <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. 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 /> 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 /> 4543 Balsam Drive Morada,CA 95212 4543�I�m o 0 <br /> 4. Product Labeling: Made In Home NttZh&idesCett#FrOO23437 amain ome Ven Mo ada <br /> Ingredients: `^°" La ectl esCCtopft 9.5 12 <br /> Attach two labels to this form fol Flou bleached wry eat floe,maned Dar eeyy,flom, rk h,,,,d�entg: <br /> made). Wadn,imn,thlamin mononitrate,dboflavin,rogc ad y - a'sf'l-iv,W,'u"4fl ; <br /> sugar,buttes,eggs,beldng der, no g. Aad 41e rma V' �*iw 6ti,. <br /> AA � .sag �,.^r7� �wki, gum mufMdYt <br /> �` 1 mmumAoalfia . <br /> 5. Water Source: ".ut.w.o�ffalo�ahic�cu..oni _� WWk:bu <br /> Please check what type of water source is b FO: Z0g si�, •co� <br /> City Water ❑ Private Well' <br /> 'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: L-,- <br /> Attach <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />