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SAN JOAQUIN Environmental Health Department <br /> —COUNTY- <br /> -� " C axe i-ve-s <br /> Greatness grows her N <br /> , 2 ( 15- 23 <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> ,3q t.Llres 'Pj.)k-e ,Skop Kri5fz K-Dk ID-29- 22 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 907 kilnraer� D - FRipUYt g531010 <br /> Website(If applicable): J Telephone: <br /> Www couareshakn_shoh ruyn 20q- - S5i,)q <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $186 "Class B" (Direct& Indirect Sales) $312 <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 /> 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:r �yYt[NV,l Cdrawtk Biu tlLtS fat uvltni� dal+edCava n,(, IL i o ` l�cdC�wart�eF,J�¢FnTrinl¢(kDabl� <br /> &Hwy,e..0 D(S -ovyu-H&ICaei(nc.o 26 y-dw"F&IL duky� (LWafKljj <br /> �s,wsi�l'infri,n,�tlsl�, PI.UvtT ir0��»t1la� (rte, ll�r Oatmayl �yr�ay, D�h�l�b�'"u, <br /> Cram q ( .r�A R.ZnhtN(LP lk W0 crac.l�, MlLmdy, PdCaW, Put AUM,Dluf of4�w H4 <br /> W i Ctris <br /> 6wkmfscd kk Mumr ti, 6y"OL.1_1 &w V-e* <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 /> Please check what type of water source is being used at the CFO: <br /> X 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.sjgov.org/EHD <br /> PI2o54031 <br />