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��C�v �JOAQUIN Environmental Health Department <br />r: <br />UNTY— <br />AUG 2 2 2022 <br />COTTAGE FOOD OPERATIONS (CFO) V^z <br />ENVIRONMENTAL ht: REGISTRATION/PERMITTING RENEWAL FORM <br />PERRMIT/SERVICE:. —7 X�� <br />%O �uslness Name: Owner Nam f _ Date: <br />CFO Physical Address: <br />CFO City: CFO Zi <br />_-Ts <br />pi 2 <br />1 s' w I s f'� <br />Website (If applicable): Telephone: (� <br />6ywW Ct V'L�f'Gln �-ham[-] I -e -, CO)C=). �d� ��o `c�-- -I� <br />1. Categories: <br />"Class A" (Direct Sales Only) $1551 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: <br />Initial if you agree to abide by the following: <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 />C' 4 401 <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). %X_e— 11 3 <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />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.sjcehd.com <br />P�O 5-N7V74 FAOO 2,66�2- <br />