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pUlry <br /> SAN.DJ OAQ U I N Environmental Health Department <br /> COUNTY <br /> Greotness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: /� I Owner N me: I/11 Date: / <br /> Zo_mo� Olen S�iO rr�+ ,�(fY1 LW- 1411&l1P0CL 2q lJ�—o�b)bn <br /> CFO Physical Address: CFO City: CFO Zip: <br /> )44A 1�1'dgewood (!;� —614'a At)rad 4. <br /> Website(If applicable). hone: <br /> Xq - 1n9-3aa9 <br /> 1. Categories: <br /> [E--'Class X (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 /> Food List: I / <br /> Szasong_-I PW e.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 /> TUhCw � ?VIA/ <br /> ❑ City Water El Private Well* <br /> Aomcc, EstaL�S, Apva� <br /> If a prI ate well, attach all updated water sample re Its (including quarterl bacteria and Nit to jesu Its.) <br /> We- ji�u� a� Complete tV,,z b P lu s y am, I n sta��ed <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 />