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` QUN <br /> SA Ns10AQ U I N Environmental Health ent <br /> ItCOUNTY <br /> °11QFQar' Greatness grows here. MAY Z 2 2019 <br /> 'ENVIRONMENTAL <br /> N PIERMM SERVI <br /> COTTAGE FOOD OPERATIONS (CFO) �SLrH <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> l Q-Z qV� aao 1� <br /> CFO PhysicalAddress: ILI"LIA 1� cwt CFO City: CFO Zip: <br /> 711 U Vv©c ww C 0a(. q's-')_ <br /> `Website(If applicable): Telephone: <br /> 1. Cateqories: <br /> r%-- "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:2A.0 <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 /> 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: -r\( a- <br /> Please check what type of water source is being used at the CFO: <br /> a 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 />