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Owner Name: <br />J Oge‘i <br />CFO City: <br />1-0 C- 143 VI <br />Date: ki 1 a.3 <br />CFO Zip: <br />Ctg 9--V 6 <br />SAN JOAQUIN <br />—COUNTY— <br />Crco:ness grows here. <br />c)C_C)•-•-l\o,1 <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />13c,I <br />sj CFO Physical Address: <br />22C117 <br /> <br />2uIL LaVie- <br />Website (If applicable): Telephone: <br />Sto—bRci—vOci <br />Categories: <br />'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: <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 />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 />: 6kvls Fivutc, So....lcu, yl/lrw E <br />vict <br />Product Labeling: <br />Attach one label to this form for one of your CFO products (only one label is required if only one product is <br />made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />g City Water 0 Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />16. 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 />.368 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 J www.sjgov.org/EHD <br />Scanned with CamScanner