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S A N'J OA Q U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name- Date: <br /> 5dJFVrkT-A(P.,S Vd VIEN BuTWI� 1- n2-53 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> ON Olwm wtvc- 5TM=N <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> 9f "Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indire,�t 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 NOTMOWOnly <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 /> 3. 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 /> ��-nk AU/ O LCAD 5 <br /> 4. 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 /> Ple e check what type of water source is being used at the CFO: <br /> 7ity Water ❑ 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. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />