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SAN 10A Q U I N Environmental Health Departm <br /> C ( ,l,l ' •— :, <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name Owner Name DAL' <br /> Fah Freeze Fyn k r q;ne We-i'pi t- 10/30/2 3 <br /> CFO ph};a_al Addre CFO Cd CFO 11p <br /> iks-2 cl-'e nfi+t cf- -, 1.dfhrap 9S33o <br /> Wel;-,de(if applicable) Telephone <br /> 209-351-1127 <br /> 1. Categories: <br /> N "Class A' (Direct Sales Only)$186 ❑ 'Class B"(Direct& Indirect Sales)$486 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: t<A-) <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br /> foods that are defined as"non-potentially hazardous"are approved for preparation by a Cottage Food Oper <br /> These foods include items that do not require refrigeration to keep them safe from bacterial growth that could <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: h1 l lErf-rZ! kl d CAt'LJ 4 <br /> ��fy . Sl�i�i'ItS, �o�_I'A.tnt:l�,�.rsy MGII'sk� of�iSr l'araws,rjT(��.rx�.v/ ,!'!'If; <br /> roll r�9vrvtn�;rs, Qirt.ao(s,Carotnul SiJci',nr k4 A% nk, rftarl�� <br /> N kt!VS_ rock, fleury Barn, ,Lerd C'lus&Z pec psr red hch. — <br /> Fr«ae ralr:ed iCe C'/^�am <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 /> Ex 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 eac individual that were not submitted with initial applicatiorI—. <br /> (including family members and!or employees). � A � <br />