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a SA 4W 4 permit annually by completing this form and submitting to San Mateo County Environmental Health for approval. • Are hands washed properly prior to preparing or packaging foods and after engaging in any activity that contaminates hands, I SAN MATEO COUNTY HEALTH i cNvit�OMWE.N AL HEALTH SERVICES 2000 Alameda de las Pulgas Suite #100 San Mateo, CA 94403 (650) 372-6200 1 FAX (650) 627-8244 smchealth.org/food COTTAGE FOOD OPERATION (CFO) FORM APPLICATION TYPE: CLASS A (1590) DIRECT SALES: CLASS B (1591) DIRECT/_INDIRECT SALES: select one f NEW REGISTRATION f- ANNUAL RENEWAL NEW APPLICATION ANNUAL RENEWAL BUSINESS INFORMATION: NAME OF BUSINESS: . 4 S CFO ADDRESS:/-? N '- h A i/ 2 CITY: 1-(26-11 ZIP: S' a WEBSITE: BUSINESS INFORMATION: . OWNER NAME: /`pr fe- -� ie II /j e - MAILING ADDRESS: /,3/ S, ('n QI✓V -rK Aaen CITY: Xall/ ZIP: .S raooass PHONE: HOURS OF OPERATION: E-MAIL ADDRESS: CFO GENERAL REQUIREMENTS MOBILE:,;,)O ��D�� tyLLt 1 � C17rA The following requirements are outlined in Section 114365 of the California Retail Food Code as minimum standards of health and safety for the preparation of approved cottage foods in the home. All requirements must be affirmed by owner and approved by this Department. CFO's are required to renew their registration/ permit annually by completing this form and submitting to San Mateo County Environmental Health for approval. Are hands washed properly prior to preparing or packaging foods and after engaging in any activity that contaminates hands, r YES NO Does the entire CFO (e.g., food/equipment storage, food preparation, product packaging, etc.) occur within the private home f - i where the CFO owner resides? my CFO from my home kitchen. Future activities must be from a commercial food facility with all applicable permits. Are infants, small children, and pets excluded from the kitchen during all parts of the CFO? ZONING REQUIREMENT The local zoning administrator may require that you apply for a permit to use your residence as a CFO. Does the CFO owner ensure that no other domestic activities. such as family meal preparation, dish washing, kitchen cleaning, tjI f clothes washinglimning, or guest entertainment occur during the CFO? Page 1 of 2 Are all items pertaining to the CFO stored in the kitchen or in a room used exclusively for such storage? Are all food preparation and food/equipment storage areas maintained free from rodents and insects? JQ r Is smoking prohibited in all areas of the private home used for the CFO, including food/equipment storage rooms, and the 9( r kitchen when cottage foods are being prepared or packaged? Are kitchen utensils and equipment maintained clean and in good repair? Are utensils, food contact surfaces, and equipment used in the CFO washed, rinsed and sanitized before each use? r Do you agree to have no more than one full-time equivalent employee? (Family/household members not included)' f Do all persons involved in the CFO have proof of completion for the California Food Handler Course? Attach proof. (New CFO's must obtain certification within 3 months of operating) Are hand washing supplies (warm water, liquid hand soap and paper towels) provided for proper hand washing at all times during the CFO? Are hands washed properly prior to preparing or packaging foods and after engaging in any activity that contaminates hands, r such as using the toilet, coughing or sneezing into hands. eating, or smoking? Are workers (including owner) excluded from the CFO if experiencing. signs/symptoms of a contagious illness? f - I understand that if my Gross Annual Sales exceed the limitations set by law (below), I will no longer qualify to operate r my CFO from my home kitchen. Future activities must be from a commercial food facility with all applicable permits. LIMITS: $35,000 In 2013; $45,000 In 2014; and $50,000 In 2015 and subsequent years ZONING REQUIREMENT The local zoning administrator may require that you apply for a permit to use your residence as a CFO. I UNDERSTAND TH j,T I MUST OBTAIN APPROVAL FROM MY LOCAL ZONING ADMINISTRATOR BEFORE OPERATING Initial Here ,ev03132019 Page 1 of 2