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A t f � i1 Q ij ; �,; Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REG ISTRATIONIPERMITTING RENEWAL FORM <br /> CFO Business Name: S %ru r Name: <br /> 4 r ^[I Dole: f) <br /> CFO Physical AdEressJA Wfl o 7 rv'(v V,/ C CIE <br /> �• O1Vl/n <br /> Wedshe(If apphcabb): /✓7 TelePhona: ' 0q. rl "1 VlL . VW V U <br /> 1. C ories: l <br /> Class A7(Direct Sales Only)$186 ❑ 'Class B" (Direct& Indirect Sales)$312 <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-bome 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 /> S <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 ck what type of water source is being used at the CFO: <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: <br /> Attach food handler certification for owner and each Individual that were not submitted with initial application <br /> (including family members andlor employees). <br /> 1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 1 www.sJgov orglEHD <br /> S <br />