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Pizos\-4 -1S <br />FA oci 2,e,D <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sicehd corn <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: <br />R ,,,,,. Bo_L,_ c_ )e4a. I <br />CFO Physical Address: CFO City: <br />iLU7 111 G- r • n e_,-.. CV . i LC-L.-I-kr 6cD <br />Website (If applicable): i Telephone: <br />- LI (05 c3, <br />}-'lry)t-It-N <br />Date: <br /> <br />CFO Zip: <br />CIS 3 3 0 <br /> <br />Cateqories: <br />21 "Class A" (Direct Sales Only) $125 D 'Class B" (Direct & Indirect Sales) $250 <br />2. Prohibited Items: Initial if you agree to abide by the following: K <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a 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 <br />of ingredients (attach separate page if needed). <br />Food List: C oo k , e , c vp(oki5 1\A \j „.,,151 B rovn:es, con Q) <br />Fru:i cubhifri, cv Or,-,,k Bii,085 1'1'14 )1(1 Lick f r;c1 pLe5 <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required if only one <br />product is made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />City Water U Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />END 16-29 6/29/2015 1 CFO REG/PERMITTING RENEWAL FORM