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Piz GS4bre'4� <br />SAN:J0AQUIN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO auwn ss Nimo <br />C <br />, pS2�5 C���CCi yes_ <br />CFO [,Zal.ktdress 11 <br />LCP3 Vv/ _b&4ct_C <br />Owner Nafw <br />I.o <br />CFO Cily <br />Date 1. I p OQ 7p <br />CdCFO Zi Cl�"3q/ <br />—Weosvlo llfappl[,Ne) Telephone'. <br />1. Categories: <br />DO 'Class A- (birect Sales Only) $155 ❑ 'Class B' (Direct & Indirect Sales) $310 <br />r <br />2. Prohibited Items: Initial if you agree to abide by the following: I (' <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 />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 wafer source is being used of the CFO: <br />R Gly Water I ❑ 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 wv v slechd.com <br />