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Website (If applicable) Telephi <br />c2Cecz\l'i 2.02,%\c-1 • GO e\-\ &co -71e. z2,gc? <br />Pg, s- <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNT" <br />Grcatness grows hcrr <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />\ SSE 442 .cke <br />pFC) Business Name. Owner Name: <br />?f—CCAt 2--Q2 4c,6 7Y-es e'ri'ft 07 <br />„ <br />/ 3 <br />CFO Physical Address: CFO City: <br />L(1 Nr" (Id(/e 0 <br /> <br />TY '2 <br /> <br />CFO Zip: <br />q 3-7 <br />Categories: <br />EI "Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $312 <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 />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: y 02 S\-e, \ID (0 4-et 2Y---5 <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 />p City Water [1 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