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1 <br /> Ix4c `s 7 SANAOAQ NIN Environmental Health Department <br /> —COUNTY— <br /> i- Greatness grows here, <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> L 1 • "2_R <br /> CFO Physical_A6ess: CFO City: CFO Zp: <br /> Website(if applicable): Telephone: <br /> H-N-GCued `�ti� 52 • S� s 2- <br /> 1. <br /> 1. ata ories• <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-bome 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 L4'kc C L, (' v.0 Q K- C(C- C wc1 `s l <br /> Ulu 1 <br /> 7) ►-1 P C=L►uU E C r N Y IN Fti B <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your.0 FO products(only one label is required if only one product is <br /> made). <br /> 5. Water Source: <br /> Pte a 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 handier 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 />