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Jpviv r <br /> - S A NA OA Q U i N Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO BusinessNa e: Owner Name: Date: <br /> M, ci(S �QclVenl�t�(ucc�s M;CIVA fn<Dorald qtz)l zl <br /> CFO Physical Address: CFO City: CFO Zip: <br /> ��7 maln, ie Ctle 95Z4)14 <br /> Website(if applicable): Telephone: (� <br /> ZOq. 5—t ClQj. �VQ�/f7 <br /> 3 <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $155 Z'-Class B" (Direct& Indirect Sales) $310 ,,, <br /> 2. Prohibited Items: Initial if you agree to abide by the following: —'qAk <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br /> foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list of <br /> ingredients(attach separate page if needed). 1 1 --,,,� JJ <br /> Food List: CkJyafrtd Apj))e.S�ocAak C_il� TY4�l�1Y)UtlaW$. <br /> ('o tttUl cl, ca p . ckocola �; c�K�res <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 /> Please check what type of water source is being used at the CFO: <br /> �Ity 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 />