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•` �� �y SAN JOAQUIN COUNTY o <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />'' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />0 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.s ov.or /e d `FC 3,9 <br />,`//Ij"f <br />' f ft;i wt yC�� <br />COTTAGE FOOD OPERATIONS (CFO) ��cFSTH <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Date: <br />L"AX0L1A/E"S CO-r-rAcL K UCIIEEK 1,;?/3L0 60/y. <br />CFO Physical Address: CFO City: CFO Zip: <br />35 iANNE)-i►CL 7)R, M4N CC4,CA ?5331 <br />Website (If applicable): Telephone: <br />-0 823 2322- <br />1. Categories: <br />"Class A" (Direct Sales Only) $125 "Class B" (Direct & Indirect Sales) $250 <br />2. Prohibited Items: Initial if you agree to abide by the following: 'l <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food -borne illness. <br />3. Products: <br />Provide a list of all products you are preparing. If preparing jams, jellies, or nut butters include a list <br />of ingredients (attach separate page if needed). <br />Food List: <br />N 0 tj A IN G C..:S A S ST YC A <br />4. Product Labeling: <br />Attach a label for each product that is being prepared. (A label is required for each product being <br />prepared). <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />X City Water ❑ Private Well* <br />*If a private well, attach all updated water samples (including quarterly bacteria and Nitrate results.) <br />EHD 16-29 1/6/14 1 CFO REG/PERMITTING RENEWAL FORM <br />