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,.�you W••,. <br /> ,_'° -°t SKJOAQUIN Environmental Health Department <br /> ,I <br /> —COUNTY— <br /> Greatness <br /> COUNTY— <br /> Greotness grows here. - <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Na e: caner me: ate: <br /> v . C�y�I W", �G l 0 0, Oygm a& V61 L2, Z <br /> FO Physical Address: CFO City: CFO Zip: <br /> GM �.� m� e eY s� 2S Cal D/\-., <br /> Website(If applicable): Te_ h C <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: <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: Se-G..,<,- <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 /> ZPie se 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(m',�dividual that were not submitted wi h initial application <br /> (including family members and/or employees) l 1Q�e ft j V a'I ( Yfi I 41 �L <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1\�I �twwlwl .sjcehyd.c m <br /> PCO"`f T1 <br />