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� P, S 1 e C1 I <br /> SAN ;J O A Q U I N Environmental Health Department <br /> COUNTY_.. __ <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> \ REGISTRATION/PERMITTING RENEWAL FORM <br /> .C`O BU <br /> s s N e: , I� Owner Name: Ih k^I ���rl S Date: I I 12,O� <br /> v �L C IN W+ , 1 <br /> iCFO Physical A ess: � CFO City: <br /> w1 � ^�CI <br /> FO Zip: <br /> Website(1f ltile): Telephone: "/1� ^ n h , 1)C V,l <br /> 1 ate ories: <br /> I <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 LOVD. 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-bome 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 /> r 1Fo1od'List: <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 /> ,phase check what type f water source is being used at the CFO: <br /> �`(�CityWater r��tnN` �C`Pq')�� U0- ❑ Private Well' <br /> `If a private well, attach all upda of d 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.sicehd.com C <br /> C <br />