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SAIll AQUIN <br />CGI_1N-V <br />Name: <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Owner Name: <br />Date: <br />CFO Physical Address: CFO City: t CFO Zip: <br />I -IK S0"',-00VV\ ST NAYn4c� 1533 <br />Website (If applicable): Telephone: <br />oO°li Q ll l�-U(Ai.-Ig <br />I. Categories: <br />X'.Class A" (Direct Sales Only) $186 <br />2. Prohibited Items: <br />❑ "Class B" (Direct & Indirect Sales) $312 <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: _Fr-encyN �ka.0g✓ OYES kn O -Vh I T'Va y� CfAn <br />4. Product Labeling: <br />Attach one label 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 />It 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 J F 209 464-0138 1 www.sjgov.org/ehd <br />