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P'1S19-to <br />SAN JOAQUIN <br />C 0 Ll N <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name. 1.) <br /> OW/ CVASt'l <br />CFO Physical Address , <br />Ave. <br />1. Categories: <br />• ciass A - (Direct Sales Only) $186 LI Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: <br /> Initial if you agree to abide by the following: tki‘ <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 />Wetstte (If appl <br />CFO City <br />itvo r <br />Telephone: <br />Tog V10_- '4 1160° <br />Data: <br />0 (1/1// <br />CFO Tip <br />qs--3so <br />Fttrides <br />Pkto <br />KtA4-s'ina <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 />2 City Water LI Private Well' <br />if a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />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 I 1 209 468-3420 F 209 464-0138 I www.sjgov.org/EHD