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SANs10AQUIN Environmental Health Department <br />r , <br />—COUNTY— <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name. Date <br />_Ain5lir I�Ine� CDOVio GhkAiQ kLd'"11 WOOCf 2-1l'Z2 <br />CFO Physical Address. CFO City, CFO Zip <br />�,N �1�10 E acl�ul�YLl11 Lei g9242 <br />Webrute (If applicable) Telephone. <br />www c� Uq-1o4c1 X7134 -- <br />1. Categories: <br />rP -Class A' (Direct Sales Only) $155 ❑ 'Class 8' (Direct & Indirect Sales) 5310 <br />2. Prohibited Items: Initial If you agree to abide by the following: �IZ <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-bome 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 />111111YOW "R VA <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 />S. Water Source: <br />Please check what type of water source is being used at the CFO: <br />ii'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 209 468-3420 1 F 209 464-0138 1 www sjcehd.com <br />