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Q'� ` <br /> , SANPJOAQUIN Environmental Health Department <br /> —co U N T Y <br /> �cq�,Foa�'=pi Greatness arovvs here <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> Myctrla.5 Cookies `71x.1, & U461)nI 1.Z -12- - I � <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 151 Moke_I IAmne_ R%ver '>r Lod ► Ca. 61-�'2.` 0 <br /> Website(If applicable): Telephone: \ <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 AL OWED. 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: a2 �A� <br /> Provide a list of all products you are 1A14ies, or fruit butters include a list of <br /> ingredients (attach separate page if 1%1..., s <br /> Food List: 1�� k 1 S <br /> Juli Quashnick <br /> (209) 482-29,23 <br /> w-ynanascookies@gmail.com <br /> Instagravn/Facebook <br /> Made in a Home Kitchen <br /> Permit+r: 1 Mokel-0A5956 -San Joaquin County <br /> 1S'1 Lodi, <br /> CA <br /> River Drive <br /> Lodi,CA asA40 ✓'l <br /> Pecan Shortbread Cookie <br /> Ingredients: Flour,butter,sugar,pecans,vanilla <br /> Contains: Wheat,nuts <br /> (Made in a kitchen that uus nuts) <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 /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> YCity 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: <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> 2 tI <br />