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LA <br /> SANAOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> lk Cir�� "1-o t►Q C°. (°_tK_rro l L. Ir6 l woU -kUh 4P f Lip( X-24 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> -616 Ay beckr&ske�, S\JQ V'\C)-YL_0- gS-33-- <br /> Websile(If applicable): Telephone: <br /> Wv�uS, a\\txbow}k4�b\ex,c1, corn Aoci- 9ta - uyowa 510 -3o1 -oI0 calf <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: OAS <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-bome 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: 5 e-V-.S0V-WA N-LA eo-,:,pn k!b %\,4 n CA <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). S e.e_ Nt k Q c1 tafL <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> [wily 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 /> S <br />