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C11 <br /> ` SA N.�J OAQ U I 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 /> .Sw22A -� ee . yn� ft Ham- 2,-)Z - 2D 20 <br /> CFO Physical Address: CFO City; CFO Zip: <br /> 3225 Lx,rc�mon` C4 95-201 <br /> Website(If applicable): Telephone: 9-39V <br /> 2 <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 /> ri <br /> Food List: g�f rCL," S1�CL4 Lou IL�e s mow«, civ L 42 <br /> CII�QL�.. dY`t� t p ✓�cn �1.� i �p�c�5SC7YK5 ck4c lclk cc,:,) CLIO[L_e__5 � <br /> C(IQLOLL t cls.,n LQ o�: S �1, e� P <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 /> R.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 />