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�`auih <br /> °�� SANAOAQUIN Environmental Health Department <br /> \' fit ` —COUNTY— ADD� S� <br /> f tin <br /> e"141F0 ��P Greatness grows here. PA D6yS 83 <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL F=ORM <br /> CFO�)�mt7lfess Name:0e�1 �� Owner Name: l4 m Vt.�t' IAy o Date: I �I <br /> CFO hysicalP Address: CFO City:. V CFO Zip: <br /> 5�ip� �,e sic k arac n 3a-a-7 <br /> Website(If applicable): Telephone: <br /> �26�11/-t3o- 1or133 <br /> 1. Categories: <br /> X "Class A" (Direct Sales Only) $155 ❑ "Class 13" (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 /> r c x>yr-eS <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 /> REF.KENFO <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: APR 2 6 2021 <br /> , <br /> � City Water EJ Private Well' ENVIRONMENTAL HEALTH <br /> /� PERMIT'SERVICES <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 />