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PP, OS�1��_iHii, <br />SAN _ J O A Q U I N Environmental Health Department <br />—COUNTY— <br />Greatness grows herr RECEIVED <br />COTTAGE FOOD OPERATIONS (CFO) FEB 17 2023 <br />REGISTRATION/PERMITTING RENEWAL FORM <br />r NURONMENTAL HEALTH <br />CFO Business Name: Owner Name: MIT/SERVICES <br />� ay (AVIA �XA wt� F��frneC \�2-1 (7[a <br />CFO Physical Address: CFO City: CFO Zip: <br />N-Sh)ek-an \fid- Uode ,r\ Q523(p <br />Website (if applicable): Telephone: <br />201`�I- 35 15361 <br />1. Catenories: <br />X"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: _iN�7 <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: 0Q5\6e`)t CCG\ \[P S ICC1��, CCA «Sr CCA O&P r-, <br />r 4\Moocv_ d(I;yga :pye ize s : S(ore5 <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). I <br />5. Water Source: pfd <br />Please check what type of water source is being used at the CFO:nrn�e r�C I IZ� I c3 <br />El City Water Private Well' \ \ t� �`� <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />6. Food Processor Course: (Yl, <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 />6 . Pe-kerscn \\16905nb .\. corn <br />