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SAN J OAQ U I N Environmental Health Department <br /> COUNTY <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> 'Vilem del �a �t �rrns tall VUIi �,11,1fi Iva $-31'2 / <br /> CFO Physical Address: CFO City: CFO Zip: <br /> Cr. 6..1 Mum cAc.lkbtl qs'a v y <br /> Website(If applicable): Telephone: <br /> CZo�'7 (v�Z�USl2 <br /> 1. Categories: M 5! lVa ne f r<ac�o�S, rte <br /> &( "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: I <br /> Lgye�lobir & 11244MI'L I/Ihp!jar <br /> I uvendrr c('hy�l bvmaa� �f <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label ME d ii�nit� ot is <br /> made). D <br /> 5. Water Source: OCT 0 ? 2021 <br /> Please check what type of watersource is being used at the CFO: ENVIRONMENTAL HEALTH <br /> City Water ❑ Private Well* PERMIT/SERVICES <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 />