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L <br /> SA N J O A Q U I N Environmental Health Department <br /> -- COUNTY-- - <br /> f� rrr7frr'iwt hr r <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO B Ines Name Owner Name: Data <br /> �a inl� �� �A� LD04 C �T�r_� <br /> CFO Ph ioal Addnse: CFO City- Cp0 zi <br /> —1-7 . -7 QOter�r�sc ESO&a CA q1 3ZO <br /> j <br /> Webaita(If app6cabk): Tek hone: <br /> ---Z�y yob 7 5(o7 <br /> a 1. Categories; <br /> 13''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 NO A LOWED. 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 /> e <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 /> ;Wd L9 <br /> .� <br /> 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 /> 6. Water Source: <br /> Please 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 F 209 464-0138 www.sicehd com <br /> f: <br />