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A Q SANAOAQUIN <br /> Environmental HeIRRt"ent <br /> —COU NTY— <br /> cq� Pt Greatness grows here. OCT 2 1 2020 <br /> COTTAGE FOOD OPERATIONS (CFO)LNN'lliONiN►LN'rAL►1EALTtf <br /> REGISTRATION/PERMITTING RENEWAL FORM D►.I'AIZTl%tLNT <br /> CFO Business Name: Own�f Name: r,. Dat <br /> � & �2n�t �S C O�rot�2iG1 9�2� 2.0 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 05?2 fA&UO lW519 <br /> Website(If applicable): Telephone. <br /> 1. Categories: <br /> _.—❑—"Class H' (Dwect Sales Only) $155 "Class 3"'(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: _G„� „ C <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 /> ❑ 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 209 464-0.138 1 www.sjcehd.com <br />