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a SA N --J U U i N Environmental Health Department <br /> Lot _ COUNTY <br /> n9a" Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> M <br /> CFO Business Name: Ow <br /> � �nn <br /> ge <br /> }r Name: Date: <br /> I ??C,I,o?i('S Ilke_glenAk Sir I"1iGkbc� I� CDCn,ita / ! / ZOO <br /> CFO Physical Address: 1iCFO City: CFO Zip: <br /> (p7 C tl. -11- 3�c_�hj" R5-2-o q <br /> Website(If applicab e): Telephone: <br /> Zak• s18, 1373 <br /> 1� ClasosrA" <br /> C ies: <br /> (Direct Sales Only) $186 ❑ "Class i (Direct & Indirect Sales) $486 <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 /> Q6t-0i . <br /> +rsk ,K.�((��s C�a��l�i <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 /> Pleas check 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 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 /> F1'O S-q (0Z0 3 <br />