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' COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Business Nam %� Owner Name: IVULU% 6s fe^-p', ('t-C— Date: <br />OT <br />CFO Physical Address: CFO City: CFO Zip: <br />- � 13 <3b 1214 L#A±=,V c Cr <br />Website (If applicable): Telephone: (, <br />1. Categories: <br />"Class A" (Direct Salesnly) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: <br />+ALLWED. <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT 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 />Food List: <br />d S F c 6�� . t5d_" <br />4. Prodt7idt 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). V__' <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />Lv CityWater ❑ 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 />S <br />