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PR 25r�d 432 <br /> SAN JOAQUIN Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATIONIPERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> _per_ �_f�1r�f��`el�ce n-t }:c`Cc rf 3-17- �G <br /> CFO Physical Address: CFO City: CFO Zip: <br /> /974 {has /}Ielic cC ✓9 533G <br /> Website(If applicable): Telephone: <br /> 'I. Categories: <br /> ❑ "Class A" (Direct Sales Only)$186 M "Class B"(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: A -r� l $6c. we 5 45.�� 6 e t S 45*r�� t <br /> V cyfA-O d L� St PA TkLC. <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 /> N 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 F. Hazelton Avenue I Stockton, California 95205 1 T 2D9 468-3420 1 F 209 464-0138 ] vrrrrr.sjcehd.com <br /> S <br />