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SAN JOA 0 U I N Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REG ISTRATIONIPERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: �Ita+resP��aShca� KrztSrw kcittt_ 1114l21 <br />CFO Physical Address: CFO City: CFO Zip: <br />20-4 Ltty&Ev_4 Die- 9631 O <br />Website <br />(if <br />.apiplic �uo v25blalr�ShG�o.rr%M 20q-1,,[fl l'S50q <br />1. Categories: �e,,,(f <br />El "Class A" (Direct Sales Only) $155 Ipt "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: <br />Initial if you agree to abide by the following: 11-C <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 />Peo syG'y3 9 <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 <br />/arUate page needed). <br />Food List: rtlaNl�.2t[li/�iS dyUwllet Jd(4e?.)k no,ly,)wX <br />5{u.;,� <br />4. <br />Attach two labels to this forth 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 www.sjcehd.com <br />S_ <br />