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-1.67^4•idY7Y!'11r <br /> 2 <br /> ' SQN�:,JOAQUIN Environmental Health Department <br /> COUNTY - <br /> - <br /> oyc,Fcsi,,' GreotnFss grm�s herr <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> G�O Business Name Owner Name. Date. <br /> S Ll a rug - t��e �✓ - -- Alot _/ c <br /> CFO ys cal Address 0 City' CF p <br /> tAJjr <br /> Website(If applicable y Telephone: <br /> iuu i / . Ord e r'S ��5 aick r`Us�l e� !_a t-'l <br /> 1. Categories: ��JJ <br /> M' "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 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: flf C ILC 1k T bread P V! h< Q�nl <br /> baCS <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: <br /> Pe check what type of water source is being used at the CFO. <br /> XCity 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 /> z)cannea v <br />