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— - a <br /> SAN 10AQUIN Environmental Health Department <br /> COUt IT 'S <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name Omer Name Date <br /> MY PAMPAS ANNE B CARORO 10112.2019 <br /> CFO Physical Address CFO City CFO Zip <br /> 4347 BRODIE WAY STOCKTON 95246 <br /> Websde(11 appl-cable) Telephone nG� SQ T rte/_v <br /> I. Categories: <br /> El 'Class A'(Direct Sales Only)S155 ❑ 'Class B"(Direct d Indirect Sales)$310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: /vv <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 Mems that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-borne aness <br /> 3. Products: <br /> Provide a list of all products you are preparing. If prepanng jams,jellies,or fruit butters include a list of <br /> ingredients(attach separate page if needed). <br /> Food List <br /> Spiced Apple Cider Vinegar <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 /> © 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 handier 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( T 209 468-3420 1 F 209 464-0138 1 www.sjcehd corn <br /> I <br /> �.- <br /> Scanned by CamScanner <br />