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f � -moo 2333 <br /> SAN JOAQUIN COUNTY 5`lQg� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1668 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> {Fativ Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www..slcehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> y <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> S s <br /> CFO Physical Address: CFO City: CFO Zip: <br /> ,vI �5�v310 <br /> Website Of applicable): Telephone: I <br /> 1. Categories. - - <br /> ❑ "Class A" (Direct Sales Only) $125 "Class B" (Direct & Indirect Sales) $250 <br /> 2. Prohibited Items: initial if you.agree to abide by the following; <br /> I: r Foods containing cream, custard, or meat fillings are {potentially hazardous and are NOT ALLOWED. <br /> Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br /> Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> I - <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, orfruit butters include a list <br /> F of ingredients (attach separate page if needed). <br /> i' Food List: <br />'� Sr�icYerdo e - <br /> i _ <br /> i 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one <br /> product is made). <br /> '5: Water Source: <br />' <br /> Please check what type of water source is being used at the CFO: <br /> City Water ❑ Private Well* <br /># l *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> S' EHD 16-29 6/29/2015 1 CFO REG1MR1V117rING RENE=WAL FORM <br />