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SAN JOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> �F10 Business Name: Owner Name: 2 Date: / <br /> 1VOt b tV-f-0�Q 6 lo IV)- n-cCd (c. Munoz LI'Z,Z <br /> CFO Physical Address: CFO City: CFO Zip: <br /> �CtCe -�n-Ce44 L'". 5-3 +6 <br /> Website(If applicable): Telephone: <br /> s70 Lrlg 12gS <br /> 1. Categories: <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:�VDA4_ <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). a Food List: S bl1GxS f �Cj�GrG�tlC+i PC1S� f1 Q� Cc1f�L�y <br /> rn(A41nS cc,IJ <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 /> Pleape check what type of water source is being used at the CFO: <br /> 02 City Water ❑ 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.sicehd.com <br />