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_61 <br /> '� °G, SA N.J OAQ U I N Environmental Health Department <br /> --COU NTY <br /> \` cyIF6, Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: t7 Al aE-� <br /> CFO Physi al Address: CFO City: CFO Zip: <br /> X04( 16zf�, J- .In GVH- q.!�36V <br /> Website(Applicable): Telephone: <br /> ' 2flti 1 Z/ <br /> 1. Categories: <br /> "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: �I11 � SYr.�V✓du t5 6wita-Sr ��n•� ; <br /> r_"4_ lu'Cwel w j►mss <br /> I t�:cs <br /> W4 d(.0, (,(,v►,�►, 61,V, <br /> cotkcs I dot NAtMJL= 6 j d/V, <br /> t n w rl ,w�— i,LXt <br /> i <br /> C��, 4. Pr uct Labeling: <br /> A ch two labels to this form for two of your CFO products (only one label is required if only one product is <br /> ade). <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> 0 City Water ❑ Private Well* <br /> / *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> J 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 />