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N <br /> _'� :c°��� SAN J 0 A Q U 1 N Environmental Health Department <br /> ---COUNTY <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> ��nS1ic� lr,,Yle.Coo e. Sd�� r�-1 l2-l�-Iq <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 22-i &Caako_Pk • Iz'l g524t) <br /> Website(If applicable): Telephone: <br /> W1pJ W. G iY1�,lte�ptvl�.CaD1�ie 5rudi o •c pVyl tel- W- 3234- <br /> 1,(pi i e@ i n S,l i c� a►n c vn k t 5 i uc�o <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) 515.5 ❑ "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: <br /> 1 -)-)UN fA 3u ox Co�1Gc 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 /> '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 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />