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P R 0 S �-A -7 'A <br /> SANJOAQUIN Environmental Health Department <br /> --COUNTY– <br /> COTTAGE <br /> —COUNTY– <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Omer Name' Date <br /> -t--S�AC�. -C1X'� I�Q•I-�1P� QUS�"YOYY� (ollf�__,-__.al <br /> CFO Physical Address: CFO City: CFO Lp: <br /> 11 p11 S -Croc Wn on S3-- -Mawi n I Muse 9539 _ <br /> Website(11 app1icaWe): Tele ane: <br /> -- b -3R 1 -(da34 <br /> 1. Categories: by s�f �CC\@ SL r <br /> x "Class A'(Direct Sales Only)$155 ❑ "Class B"(Direct&Indirect Sales)$310 r`I <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-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 <br /> [)eC;org--e,d SuQn r Cupp eS <br /> J 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: <br /> Please check what type of water source is being used at the CFO: <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 mdth iAir^I 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 />