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SAN J O A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name Owner Name Date <br /> Mr M d1A ' S _mnK><_P_S _J a- QS <br /> CFO Physical Address CFO Cdy CFO Zip <br /> Website(If applicable) Telephone <br /> 1. Categories: <br /> 0 "Class A" (Direct Sales Only) S186 ❑ "Class 13" (Direct& Indirect Sales) $486 <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 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-bome 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- (7 co K lip—S <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one product is <br /> made). <br /> S. Water Source: <br /> Please check what type of water source is being used at the CFO <br /> City 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> �c <br />