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\C-Vc Mkt\ Vt'kkosexik_ <br />CEO Physical Address CEO City. CFO <br />CFO BusinessNem*, O'. norName: Date' <br />LcAiTc), (&-c65ctu) 'srgica -3 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />00 N 7 ste <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />kCeic-1 CLCA_ cls3Co& <br /> <br />Website (it appkable) Telephone' <br />—1 a C)50) IDG6int ss <br />Categories: <br />yr "Class A" (Direct Sales Only) $186 E Class B (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial If you agree to abide by the following: L <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 />c c\r\ omcv\ \A-A \ <br />c co\cur.-Th <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 />Plepetheck what type of water source Is being used at the CFO: <br />It City Water 0 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! Stockton, California 95205 1 1 209 468-34201 F 209 4640138 I www.sigov.org/EH <br />- 1C.Ck c)ex--,CnckA