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nUik �Z SA NA 0A U I N a <br /> ° Q Environmental Health Department <br /> " -riCOUNTY— <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Ownerk b it r �J)C_OV rC� Date: I L <br /> CFO Physical Address.- CFO City: CFO Zip. <br /> 12.1 bJP -1- AVef)+t no 6-ue, 05e ; cc,, �j3Gl <br /> Website(If applicable): Telephone: <br /> 1. Cate ories: <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: fD <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 /> �P Ian f r - 1�-i e S �' l .f� 6► e �z �L <br /> ro(-Ir F)a1�2 COD <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 /> Ve 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />