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SAN J O A Q U I N Environmental Health Departme t <br /> COUNTY— ,, a�� <br /> Greatness grows here. <br /> _ MAY 0 1 2V3 <br /> COTTAGE FOOD OPERATIONS (CFO) ARONMENTALHEALTH <br /> REGISTRATION/PERMITTING RENEWAL FORM PERMITISERVICES <br /> CFO Business Name: Owner Name: Dat <br /> CFO Physical Address: CFO City: �CFO Zip: <br /> J <br /> 1336 qid MVrrf M aryltW 33L0 <br /> Website(If applicable): Tel hone: <br /> �5 5 50 .95►�� <br /> 1. 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 /> 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: e : ? r-D , Care <br /> C J' rn) <br /> C _ <br /> 6n P.�)arg Ltmyn Round cam <br /> 4. 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 /> 5. Water Source: Q � Cc, <br /> Please check what type of water source is being used at the CFO: <br /> [City Water ❑ Private Well' <br /> L <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.sjgov.org/EHD <br />