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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />cro Business Name. <br />Tine W -fr"..tkket <br />CR) Physic:slress: CFO Citr <br />4-5 pot,uyvi 1021 kiecry, <br />Webvt.t 3CVIC-14,44:, hone. <br />2,04 —Ct 13— OS Ciq <br />1,tit. <br /> <br />- <br />CFO 7c <br />5-3C4 -.• <br />Categories: <br />s A' (Direct Sales Only) $186 71 -ctoss Er (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 defned as 'non-potentially nazardous- are apprdved preparation by a Cottage Fond Operaton. <br />These feeds include items that do not require refrigeration to keep them safe from bacterial growth that could Le a <br />cause of food-borne illness. <br />Products: <br />Provide a fist 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 />F.C.C4 LiSt. f Sizaptt i2t4.tt-tv-cA-eArl-ts ooLe5 , r 4S' (4,-140S1 <br />rOdS t OTOLIA:6'<-4elefed t CiA,14( eves, e&fraincist_ <br />acjAajzz ied-cs cietipkes51 OY'01.0.11,1,;{S <br />oa° <br />Product Labeling: <br />;,7.3ot. one label to this form for one of your CFO products (only one label is required if only one product is <br />Water Source: <br />PfeaSo chock what type of watet source is being used at Ibe CFO: <br />City Wate! 0 Private Well' <br />*If a private well, arieCh all updated water sample results (including quarterly bacteria and Nitrate results <br />Food Processor Course: <br />Anacn food handler certification for owner and each Individual that were net submitted with initial acplicatlon <br />(including family members and/or employees). <br />1868 E Hazelton Avenue I Stockton, California 95205 j T 209 468-3420 F 29 464-013B •www.sjgov