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SANJOAQUIN Environmental Health Department <br /> COUNTY— (L n O 2 S �p <br /> Greotness grows here. ` J <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> swef c.tp,W IQ7 2 Mo lqQ i ) AWOL i 11 o a-4 - QDQA <br /> CFO Physical Address: CFO City: CFO Zip: <br /> ►8g4 woteu ulm tw'Ive, La nmp CA 95 0 <br /> Website(If applicable): <br /> 1. Catetaories: <br /> ®' "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct& Indirect Sales) $310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: L <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br /> foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list of <br /> ingredients (attach separate page if needed). <br /> Food List: sugar COCKAt& <br /> C>01.11174 FTe a CQkQ, <br /> Dowry Flee. ."COk <br /> c howtate DLwd Pte t2kj.s i Daeo.S <br /> Dmn Free n ClC0Jr0_)& <br /> 4. Product Labelinaa: <br /> Attach two labels to this form for two of your CFO products(only one label is required if only one product is <br /> made). P 2—<:k 2A <br /> 5. Water Source: G11-:4r�� 12O 41 g$ (B <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 /> S. 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 />