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C6 <br /> �Z SA N.D10AQ U I N Environmental Health Department <br /> fQ <br /> " ---COUNTY - <br /> �',•c�\fP Greatness grows here. <br /> RlF�ftb COTTAGE FOOD OPERATIONS (CFO)REGISTRATION/PERMITTING RENEWAL FORM JAN 1 <br /> ENVIRpNME � 20 <br /> CFO Business Name: Owner Name: DafeERM1TjS R��CeACTj, <br /> I� �►' Abki�s Ci s _ I l ES <br /> CFO Physical Address: CFO City: CPO ip: <br /> Website(If applicable): Telep one: <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: �hbCJU gort srto ocsl,� Port- Sfiv ccdy` . O <br /> CbGhib <br /> -� ; <br /> & r Svye,J'. �� c��[a�0.ci f'J. MOnyc. . PAWSj�� '"rr y <br /> �� J <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 /> K 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.corn <br />