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a� t♦i , <br /> t. y� SAN .JOAQUIN COUNTY c <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Q <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sicehd.20m QpR 0-11 12016 <br /> COTTAGE FOOD OPERATIONS (CFO) PfgMlTs(RTy <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Bmingss Name: - Owner Name: /� l , Date: <br /> 0 ca-Alf$ �nvtL�tPS l�lyV1f( �Qjf1P YY�FC11, ?J '3� IU <br /> CFO PhysicalAddress: - CFO <br /> �City: CFO Zip: <br /> -132 CO*gAIn U 1'locyN <br /> Website(If applicable): Telephone: <br /> 1. ate ories: �P <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: <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 fruit butters include a list <br /> of ingredients (attach separate page if needed). <br /> Food List: Cylbk_10,5 CAO 011-5 PU�'4i� PLYee, &Oa✓) <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 <br /> product is made). <br /> 5. Water Source: <br /> Pie a 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 /> EHD 16-29612912015 1 CFO REG/PERMITTING RENEWAL FORM <br />