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SANsHAQUIN <br />COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />F 002q(03 <br />pp\ o5q35 al <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: <br />Suga Rushd Gaxione Inc <br />CFO Physical Address: , CFO City: <br />619 W Magnolia St Stockton <br />Website (If applicable): Telephone: <br />SugaRushd.com <br />97879033 <br />Categories: <br />"Class A" (Direct Sales Only) $155 fl "Class 13" (Direct & Indirect Sales) $plo <br />2. Prohibited Items: Initial if you agree to abide by the following: GD <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 />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: Fresh baked warm pastries, breads, and goods <br />Date: <br />4/20/21 <br />CFO Zip: <br />95203 <br />Orders e_ sut jartishcl co "1 <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required <br />made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />City Water D Private Well* <br />if only one product is <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 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com