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SAK J0A0UIN a <br />` Environmental Health Department <br />—CQUNTY— <br />'`c9crFoa"?% Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />,::11Z1-) 5o?A50j4 IyIH417 3 N,U95WV V -w F190 !0 —1 —21 <br />CFO Physical Address: CFO City: CFO Zip: <br />118o b F. PO(/IZ I+ _9T STo C4TON , " 957-lS <br />Website (If applicable): Telephone: <br />q3D-5�oa / 9yg-2499 <br />1. Categories: <br />10— "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: <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 />`;JAMS � 94V 125 <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 />®.City Water <br />❑ 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />