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SAN JOAQUIN Environmental Health Department <br /> - -COUNTY --- <br /> RECEfVEI) <br /> COTTAGE FOOD OPERATIONS (CFO) AUG C 9 2018 <br /> REGISTRATION/PERMITTING RENEWAL FORM "OR"MENT,gt H <br /> PERMIT/SERwCErH <br /> FO Bu 1ness Name: Owner Name: Date: <br /> P'1 f11 eC/1 I <br /> CFO Physical Address: CF ity: CFO Zip: <br /> Lh. YYlan l , 9533 <br /> Website(If applicable): Telephone: <br /> -7ga - af,�3z <br /> 1. Categories: <br /> 0 '.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: IC Q S C(( vp)Us coo k:t t s YY1el,cro✓ S , <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 /> Please check what type of water source is being used at the CFO: <br /> M 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 /> S' <br />