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SAN 10AQUIN Environmental Health Department <br />i."yfr.," —COUNTY— J ���i� VED <br />Greatness grows her <br />JUL 16 2021 <br />COTTAGE FOOD OPERATIONS (CFO) ENVIKONMENTAL HEALTH <br />REGISTRATION/PERMITTING RENEWAL FORK 3ERMIT/SERVICES <br />Business <br />Name: <br />Date: <br />CFO Physical Address: CFO City: CFO Zip: <br />A]1,9 .-) 4i "'J„ ,V19A AI- /lAnm L gala- / f - <br />Website (If applicalle): Telephone: <br />a09 -/*9- � 9 <br />1. Cateaories: <br />ED— "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:. LIC <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: /311�YlEn�iC SCo{is(1 S�D1JY?Rd <br />S�asonal Evil Dies <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 />6. Water Source: qq���"_ <br />Please check what type of water source is being used at the CFO: e mrnfJn s 4r YV� 1 <br />❑ City Water El"SzPrivate Well* Atok bes <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 j F 209 464-0138 1 www.sjcehd.com <br />fpc)�"-LI ay <br />