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SAN JOAQUIN Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />N t�N's ShorY� Swe_LA_ <br />Owner Name: <br />"ancv <br />Date: <br />k)AL-ID2 q <br />7 2 21 <br />CFO Physical Address: <br />CFO City: <br />CFO Zip: <br />539 KrOL -AN )AT[ <br />c) iv_L <br />LUCU S <br />24 U <br />Website (If applicable): <br />Telephone: <br />1. Categories: <br />❑ "Class A" (Direct Sales Only) <br />$155 <br />"Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: <br />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 />7 -Z) LA &_1 A4� <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). <br />5. Water Source: <br />Pnlesase check what type of water source is being used at the CFO: <br />I� 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 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 />