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4T44i 1+,r .. <br /> — '� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> abR Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.s'cehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: f Owner Na e: Date: <br /> Ru,ss;;;Vt V Kr, � t-z ilw _ +2_1 -11 <br /> CFO Physical Address: CFO City: bdiCA q5 <br /> CFO <br /> Zip: <br /> L <br /> Website(If applicable): Telephone: <br /> S�r0.�w�r�aa� Cewup�fly �na taws to°L-`�g2-`(tS0 <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $133 1f "Class B" (Direct& Indirect Sales) $265 <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. <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 /> 3. Products: <br /> Provide a list Of all products you are preparing. If preparing jams,jellies, or fruit butters include a list <br /> of ingredients (attach separate page if needed). 1 <br /> FoodList � CAV1r� �rJYU �tlPy0.V` t �dtY (,(kl^ SNrwp <br /> fNv� t)aVL�c N l� °0 Ci A <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 <br /> product is made). <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> ❑ City Water k2 Private Well* <br /> *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) C <br /> J <br /> EHD 16-29 8/12/2016 1 CFO REG/PERMITTING RENEWAL FORM <br />