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X <br /> F—A 2 <br /> SA NUJ OA Q U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness grows gP(LO5 �1 I �I�U <br /> rows here. <br /> J <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORINT <br /> C O Bu sin s Name: Owner Name: Date: <br /> dlnfi 'l�a nyCvrnmfly A_ Ian <br /> CFO Physical Address: CFO City: CFO Zip: <br /> kane Tra N qS- 3 ? -3- <br /> Website(If applicable): Telephone: <br /> Fate oriel: <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: „fd <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). 4_ <br /> // / l <br /> Food List �� Chou l tl i'Y a� le 4_d C kee �7i�=ice d <br /> 117s 1&S e_/2rz u k d_ov,��rC) oi�V Cil � eon <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 209 464-0138 1 wvvw.sjcehd.com <br />