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SANsJOAQUIN <br /> Environmental Health Department <br /> In i �1 <br /> COUNTY <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Narrte: Date: <br /> M '�rtina`� bbik%e.S "11 (s - 1r7 <br /> CFO Priysical Address: CFO City: , CFO Zip: <br /> Website(If applicable). Telephone: <br /> rrv)anksuok►es. Com (au�l) 4�� -a�a3 <br /> Lt[i �uq 5/1nI rn� I corn <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $155 � "Class B" (Direct & Indirect Sales) 5310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <br /> .C)k <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT AL WEDi. 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 there 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 prep )r fruit butters include a list of <br /> ingredients (attach separate page if neec bit <br /> 1<,.,<, ., ,hili Quaskrtkk <br /> Food List: �0�1 i e� - „ �n�•L`a (Z,pq) 482-2423 <br /> u " mynanascookies coax <br /> ./Llli Quashlaick - Instagram/Facebook <br /> (20q) 482-2-q2_3 Made in a Horne Kitchen <br /> mynanascookiesOgmail.com Permit ak: PT0025g56 -San Joaquin County <br /> Instagram/Facebook 151 Mokelumne River Drive,Lodi CA 85240 <br /> Made in a Home Kitchen - Chocolate Chip Cookie <br /> Permit 4:PT0025g56 Ingredients:Oats,Flour(wheat flour,malted barley <br /> San Joaquin County _ flour,niacin,reduced iron,thiamine mono-nitrate, <br /> 151 Mokelumne River Drive riboflavin,folic acid),butter,chocolate chips,walnuts, <br /> Lodi,CA 85240 sugar,eggs,vanilla,baking soda,baking powder,salt. <br /> Peron shortbread Cookie ingredients: Flour _ Contains: wheat,eggs,nuts_ <br /> (wheat flour,malted barley flour,niacin,reduced (Made in a kitchen that uses nuts.) <br /> iron,thiamine mononitrate,riboflavin,folic acid), <br /> butter,sugar,pecans,vanilla <br /> Contains: wheat,nuts <br /> 4. Product Labeling: `"°d``"°oneCokht°S`Snuts) <br /> Attach two labels to this form for two of yuui ury t,luuuur5 (uiuy idle iduel 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 /> City Water ❑ Private Well* <br /> "I 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 />