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Environmental Health Department p <br /> artment c,,t� <br /> —COUNTY— <br /> Greatness grows here, <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: , Owner Name: ,� at.: <br /> S W 'L-`I"� ix'S ,�'w-�C.G'1Pfr"1 S W�1 (-tel L�` L fA"I <br /> CFO Physical Address: CFO City: 'I C CFO Zip: fit,I r I <br /> �I I �,( T 401 Y'10l,� d.4/y- `i - <br /> Website(If applicable): Telephone:';2-3S <br /> I /, I q C <br /> 1. Categories: <br /> D/ "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: S <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 /> x <br /> +o C S <br /> 4. Product Labelina: <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 /> 6. 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 /> S. 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> C�ecdo,rY. - <br />