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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name:Owner Name: • <br />OneA (-;506\e_ Uk) Sovne\ <br /> <br />CFO Physical Address: CFO City: <br /> <br />\3t0.1 ?a‘nfie., c--k V\0\\r-Aet <br /> <br />CFO Zip: <br />c\5'3 31 <br /> <br />Website (If applicable): Telephone: <br /> <br />Categories: <br />LII "Class A" (Direct Sales Only) $186 'El "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: 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 />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 />fc'ee2c2_ ccV) S\AC. M C (1 \k\eS 0\v\leo\c\- cA-?Ncbo-V., <br />0\Y\ \-\\ <br />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 />Water Source: <br />Please check what type of water source is being used at the CFO: <br />Ng City Water Private Well* <br />if a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />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 />,068 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />Date: