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SAN JOAQUIN <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />MS M kC'S SWEE 1 wAy <br />CFO Physical Address: CFO City: CFO Zip: <br />1'x'3\ RAIL s<. �`If�NT�tr. c153�� <br />Website (N applicable): Telephone: <br />1/l NI SWNV X125--Dt `o\tea <br />1. Categories: <br />"Class A" (Direct Sales Only) $155 ❑ "Class 8" (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: CunCRKFS , C AKS 5 ICF KR\S,�IF 1\ZEK, Qu S aRc-TZrL.S k1- ul <br />�1 ` �En Pocz2�t C2t,OS C�u�RMi S �R� t CL QUOS I c MPwt_L \,dR1�1��ES7 <br />C,\.AluC Np9Le5 <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 />L�{ City Water E] 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 />