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i,110,. SANAAQUIN Environmental Wealth Department <br /> —COUNTY <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATIONIPERMITTING RENEWAL FORM <br /> FO Business Dame; Owner NamR: — Dato: <br /> 6W�n Bln4 as A _1 LZ <br /> CFO Physical Address: CFO fly; CFO Zip: <br /> Website(It applicable): Yelephono;� <br /> 1. Catonorles: <br /> "Class X (Direct Sales Only)$155 ❑ uClass B"(Direct&Indirect Sales)$310 <br /> 2. Prohibited Items: Initial If you agree to abide by the following: <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT-ALLOWED. Only <br /> foods that are defined as"non-potentially hazardous" are approved for preparation by a Cottage Food operation. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list of <br /> ingredients(attach separate page if needed). <br /> Food List: ` <br /> J Da.r of W+ b a V 1i V <br /> �- <br /> u tk <br /> a u yD) <br /> Cn�►rv') r\,2 c of, ckew� , 9� ► Po�' rna <br /> 4. Product Labefin : <br /> Attach two labels to this form for two of your CFO products(only one label is required if only one product is <br /> made). <br /> 6. Water Sourco: <br /> Please check what type of water source Is being used at the CFO: <br /> xCity Water ❑ Private Well* <br /> *If a private well, attach all updated water sample results(Including quarterly bacteria and Nitrate results.) <br /> 8. Food Processor Course©; <br /> Attach food handler certification for owner and each lndlvlduaI that were not submitted with initial application <br /> (including family members andlor employees). <br /> 1868 E, Hazelton Avenue I Stockton, California 95205 1 T 209 48$-34201 F 209 464-0138 { www.sjcehd.com <br />