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JAN J UA U U I N tnvlronmental tlealtn uepartment <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Date- <br /> t /� Owner Name rz //C <br /> _,3neP� S (C0�Ct� Iprt1Dnttq LLC �Elet�/ SUED i' <br /> CFO Physical Address: CFO City: CFO Zip: <br /> �( ft) Amc- C—I <br /> Website(If applicable): Telephone: <br /> U;i,orv. �v� fdCCccl ie fcavl yl� g1lb• qIq <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $186 [Vf "Class B" (Direct & Indirect Sales) $312 ✓✓CC' <br /> 2. Prohibited Items: Initial if you agree to abide by the following: h <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-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: l kkecl fibbcS CCcckps) <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). -1c,F�U�� i I] C_ U <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> E/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). Prov I Dry <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvrw.sjgov.orglEHD <br />