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K osu 7,34\" <br />SAN JOAQUIN Environmental Health Department <br />COUNTv— <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name. Date <br />h e� 13tP�.r jS611avy V4,Vur yyiad,,AdLAIn 0C--}-obe,- 25, i?3'2l <br />CFO Physical Address: CFO City CFO Zip'. <br />Intl w;,iApipr hvve 46±(, Ty,&kv CA 85'376 <br />Website (If applicable): Telephone. <br />wo✓Iz 20 g— 6 Lid -66 83 <br />. Categories: <br />If "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: All <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 />Sour dou. 6 13f't&A <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 />dCity Water ❑ Private Well' <br />`If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />8. 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 employee:' <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />