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08/26/2021 09: 42 2093345007 GILL OBGYN PAGE 01/05 <br /> y <br /> SAN JOAQUIN COUNTY <br /> A..tirj � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1666 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> a' Telopbone:(209)468-3420 Fax:(209)464-0139 Web:wkwr�sjcehd.crom <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> L t �o vLY�huG �f ef�C <br /> CFO auelnesr Name; Owner Nam,;: �i�� ' <br /> O Pn aea ye (ee q, a env, z�: rrl%''Lk%.1 �Q.YYmfT�PV{/i� 1 1 (sZ� <br /> Webalte(lrappllmbic): N I Telephone: v' `I ' <br /> 1. Catego es" <br /> "Clasa A"(Direct Sales Only)$146 "Class B"(Direct 8 Indirect Sales)$292 <br /> r� <br /> 2,prohibited Items: Initial If you agree to abide by the following: <br /> Foods containing cream,custard, m meat fillings are potentially hazardous and are NOT ALLOWED. <br /> Only foods that are defined as 'hon-potentially hazardous"are approved for preparation by a Cottage <br /> Food Operation. These foods include items that do not require refrigeration to keep them safe from <br /> bacterial growth that could be a cause of food-bome llnesa. <br /> 3, Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies,or fruit butters include a <br /> list of ingredients(attach separate page H needed). <br /> Food List: <br /> V/.%Le f S � r `/7—c* Y1 <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 _ <br /> product is made), <br /> 5.Water Source: <br /> Please chock what type of water source is being used at the CFO: <br /> City Water Private Well- <br /> private well,attach all updated water sample reerats(including quarterly bacteria and Nitrate results-) . <br /> Cf h� W aft a" V-s'e— unhI <br /> 6. FoolProcessor Course: <br /> Attach food handler certification for owner and each indwidual that were not submitted with initial <br /> application(Including family members and/or employees). W W-\fin <br /> 7. DeINM Limitation: Initial if you agree to abide by the following: r ` ' <br />