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;� AN J Q A Q U I N Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: ' ( �p Owner Nam®e:;t //�� Date: p ^� <br />I ^r liit&wte tsii. 2Ji iFfYit a1 �ylAdiill — ii' lE�,11 J <br />CFO Physical Address: CFO City: CFO Zip: <br />Website(If applicable): Telephone:,. 1y <br />1. Categories: <br />g "Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the followirwg: f`_ <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 />(1 City Water <br />❑ 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />