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ni,PV Iry.�' <br /> -{ SANAHO N Environmental Health Department <br /> 1 —COUNTY— rl/10gglVl)? <br /> Greatness grows here. �A 00 2,3-7341 <br /> ( } COTTAGE FOOD OPERATIONS (CFO) <br /> �✓ REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Nam Owner Name: Date' <br /> YY r� �oYl ee �0cl { YS � Cwf a C7ariM I I II I I21 ZD <br /> CFO Physical Address: CFO City: CFO Zip: <br /> asa► a- <br /> W bI ^ (If applicable): 1100 Y f�D <br /> 1. Categories: I( \1`i I <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: LG <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: !1 mn � co. <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 /> pd City Water I ❑ 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 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />