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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.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Bus <br /> me s Name: ` Owner Name: D <br /> go <br /> CFO Physicalss , ro git <br /> KI <br /> Website <br /> — <br /> Website(If applicable): 'U•y(/ Telephone: f I l <br /> 1. Categories: <br /> )3 "_Class A" (Direct Sales Only)$1-213- ❑ "Class B"(Direct& Indirect Sales)$250 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: 1> <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 /> 3. 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: <br /> -Dana 6q"O_kk- � <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 <br /> product is made). <br /> 5. Water Source: <br /> 7Pie se 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 /> EHD 16-29 6/29/2015 1 CFO REG/PERMITTING RENEWAL FORM <br />