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4 • SAW:JOAQUIN <br />COUNTY— <br />\o rri Greatness grows here. <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />MiOnAk 01 111 L0 <br />CFO Physical Address: CFO City: <br />MO\ )14 So.) sow v\P 11-i)(Y <br />CFO Zip: <br />q5317 <br />Website (If applicable): Telephone: (5, 0 511 <br />Categories: <br />RI "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: A41/ <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: unto 141,1 orrwm, 120t,e <br />chmon c\k,w 5m1tIZA0M 1 tAf2YAN CV11 -w WocOLATF Of IP) <br />Yt1)1,h,tv kikr\174-964-, oRfoyht mit-v soot, co cvNui Plo(ppip <br />Pivrimay, 6001) oiwnloci pts-ff/D-16 PrP12-1(A1 't)4t, <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 />[y] City Water El 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 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/EHD