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S A N J 0 A 0 U I N <br />COUNTY— <br />P (Z Su s ► —] 1, <br />" <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Dale: <br />ViViN oASN "WL V I>;mf Ai"AW G- 10-21 <br />CFO Physical Addre ; CFO City: _ CFO Zip' <br />&9 m lr('11 Mr U L TTI RO p GA AS Ii 70 <br />Website (M applicable): Teiyhoge: <br />10q-_,4fl-'f Me$ <br />I. Categories: <br />-0 "Class A" (Direct Sales Only) $155 ❑ 'Class B" (Direct8 Indirect Sales) $310 �(jJ <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 />►) OKnV'CS�L <br />2 PLATT <br />3 kVtTSLnTA. <br />4. Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required f only one product is <br />made). <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />OCity Water <br />❑ 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 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />S <br />