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Pfd osy �z q � <br /> SAN JOAQUIN Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> Date <br /> �7�CFO&sines Name(+ � �� p/�Na a ����y7y� �/ 1_ r <br /> Ir IC YVO La�.xXXla I�Yl1GC� L?Dp�S WN. IYItUe CFO ZiPJ <br /> CFO Physical PAtlreSs. CFO City: <br /> 2A.5 NLUAA Wau IQt 31> <br /> Websile(If app6wble)' Tek 20q_q?0_o5gq <br /> 1. Categories: L l Gi <br /> -Class A'(Direct Sales Only)$155 ❑ 'Class B'(Direct 8 indirect Sales)$310 <br /> 2. Prohibited Items: Initial if you agree to abide by the followin *ALLOWED. <br /> Foods Containing cream,custard,or meat fillings are potentially hazardous and are NO 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,of fruit butters include a list of <br /> ingredients/(attach separate page if needed). <br /> ) �JYC e� �J C'4`C/UI/IS TUriO� ,�Y�1,OGM <br /> ,.eS <br /> onrwt� Gu <br /> l a0 1(? <br /> "� <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 /> >�Q8y Waler ❑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.Hazefton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwwsjcehd corn <br /> puw 0S �02 .e Ca32�i'vvi�t6vL 14 1616 Zq ( 6 <br /> A R x:041366 S <br />