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Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list of 3. Products: <br />ingredients (attach separate page if needed). <br />C <br />f\N-NA <br />Food List: ")I; <br />J -r <br />C <br />SAN JOAQUIN Environmental Health Department <br />S <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Date 1 <br />CFO Zip 1 CFO Business Name: Ownei Name <br />.„...0 14 C"--. Tyg--`_..s. 14 tic 4-tcr•I __ 5----;ki4 E 1 i I A (1 C ' 1 'IN rv 1 <br />CFO Physical Address: CFO City <br />Website (If applicable). <br />010i <br />Telephone: 2S31(-1 iiEii <br />Cate cries: <br />0 "Class B" (Direct & Indirect Sales) $486 <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 />Er "Class A" (Direct Sales Only) $186 <br />Product Labelin <br />Attach two labels <br />to this form for two 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 <br />the CFO: <br />El/City Water <br />0 Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />Food Processor Course: 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. Hazeiton Avenue <br />Stockton, California 95205 T <br /> 209 468-3420 F 209 464-0138 www.sicehd.com <br />