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SAN,JOAQUIN <br />COUNTY <br />Greatness grows ne;: <br />CFO Business Name: <br />Environmental Health 9,& 6Mftvnt <br />RECEIVED <br />APR 15 2021 <br />COTTAGE FOOD OPERATIONS (CFO) SAN JOAQUIN <br />COUNTY <br />ENVIRONMENTAL <br />REGISTRATION/PERMITTING RENEWAL FORM HEALTH DEPARTMENT <br />Owner Name: <br />CFO Physical Address: CFO City: CFO Zip: <br />5 3S W . CAW C40 1,) GT MOiMATPmJ 1%u SE Cly- 15-391 <br />Website (If applicable): Telephone: <br />www•Y-&NSV1ACA17-0%gS.cOVw 1240 <br />1. Categories: <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: KE <br />Foodscontaining 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: MX4 <br />r10\.A%'21 E6(nSt SI.tCIA-k2� <br />soy A'VJ\> PA-%kPq . <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: (J o p p <br />Please check what type of water source is being used at the CFO: ` t� 3C� O C=t 1 <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 />