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P(L O S`4'7 b 3`-1 <br />-14 Oo Z'1 11 "7 <br />SAN JOAQUIN Environmental Health Department <br />--COUNTY— <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Ntrir}ame; Date: <br />rnSffw,c C'ooWs aL, cYi fjlmun2q 3/3//23 <br />CFO Physical Address: CFO City: T CFO Zip. <br />f5q.3 Durh4irt Ferrj kl. /rtic� g53o9 <br />cor;rw <br />321- 6330 <br />1. Categories: <br />0 "Class A" (Direct Sales Only) $186 ❑ "Class 8" (Direct & Indirect Sales) $312 <br />2. <br />Al <br />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: (Ao k�P f <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: <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 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 />