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<br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />C CU N <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name- Owner Name: Date: <br /> <br />fi9ex-ci I olo ).5 OA k c5 6rnerq W4 re, a si a S 07 — <br />CFO Physical Address: CFO City: CFO Zip: <br />370 Weill:7o n A re, Ala ni e-c-,k. 0.--4,p,f Vii ct 7 5 3 3 ? <br />Website (If applicable): Telephone: <br />Categories: <br />"Class A" (Direct Sales Only) $186 0 "Class B" (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-borne illness. <br />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 />660 -4775- 4-767 <br />VciA1"114 Cq(ee, <br />01010 co L —f CctLt <br />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 />Water Source: <br />Pleas,check what type of water source is being used at the CFO: <br />iIrCity Water 0 Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com