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s[p 14 2020 2 u 811© <br /> ;fr 1V Aental Health Department <br /> SANOAQUINENVIRONMEL <br /> .ri CC)(JNT — -- pERMITISE;�VI <br /> Greotness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> S <br /> CFO Business Name: v` e I fl A-s Oner Name: � ICY� i I�PFI w <br /> Date: <br /> �1 c.-f-F��I NCSE llD �}I'1 I. t S e..� Zo Zo <br /> CFO Physical Address: CFO City? '9A C- Y CFO Zip: S Q <br /> 3 f <br /> 511 W �/2am D�10 P 4• l <br /> Website(if applicable): Telephone: 2 -31 Lt Qj S <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: n. � <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 /> C7C0.+U C_,�ktuL <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).6P'rr Ac�4 cid /11 6jP <t cA 7( cl,)) <br /> 6. Water Source: <br /> Please 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 209 468-34201 F 209 464-0138 1 www,sjcehd.com / <br />