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/82-2. egeke C11-. L-0971Avw° C441- <br />Date 5__ I <br />CFO Zip <br />95310 <br />CFO Business Narne: Qwiec Name <br /> <br />-5cct.AS <br /> <br />CFO Physical Address: CFO City- <br />• <br />S Mina .46.7M- Wk. r . or-J , 1111-,E111;111._ 4111114k , imaimea. <br />Pc. :N3-0-41 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />r <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Website (If applicable). Telephone: <br />?Zs- z/z- 0B88 <br />Categories: <br />le "Class A" (Direct Sales Only) $186 0 '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 />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 />Yeq14.‘ <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 />5. Water Source: <br />xl <br />Pe se check what type of water source is being used at the CFO: <br />City Water 0 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. Hazetton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/EHD <br />