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r <br /> S A N J Q A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: 7 Date: <br /> �y�e he � �),,; .(_ rti"� I Z ,� -7, <br /> Z- S <br /> CFO Physical Address: CFO City: CFO Zip: <br /> u 1 c k-L ►AIir C �C kr1t 4"1 C Ci Cf S3CI,( <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> "Class A"(Direct Sales Only) $186 ❑ "Class B" (Direct& Indirect Sales)$312 <br /> lF <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: <br /> _C ,n CSI <br /> IV <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). t I\ C v, ,r <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> 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 handier 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 />