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P Q 1"( —q-0 r <br />P SAN JOAQUIN <br />Environmental HealthRE�EIVE <br />F�1( —COUNTY— <br />D <br />\4C4-coaN'4` G, eatness grows here. <br />JAN 3 0 2023 <br />CFO Business Name: <br />COTTAGE FOOD OPERATIONS (CFO) ENVIRONMENTAL HEALTH <br />REGISTRATION/PERMITTING RENEWAL FORM DEPARTMENT <br />Owner <br />Date: <br />CFO Physical Address: CFO City: U CFO Zip: <br />7933 K icC ��. e :5-E-ce.k{ne3 n q 5,212, <br />Website (If applicable): Telephone: <br />72-0-9-79-5782-i <br />1.. Categories: <br />EB/"Class K (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: f✓gyp Q <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: <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 />F ✓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.sjcehd.com <br />5 <br />