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al‘p ,5t1a-efac 00._ 01/4c='S, ic c <br />-2ck_2_s <br />SAN JOAQUIN <br />Cu N Y- <br />Environmental Health Department <br />cN-LDS-C9-1*S9 <br />COTTAGE FOOD OPERATIONS (CFO) CO 2-cc, <br />REGISTRATION/PERMITTING RENEWAL FORM <br />cif() Business Name: Owner Name <br />Cordra, -Tackk- Oovpn \of- <br />CFO Physical Address: CFO City: CFO Zip: <br />e -eir" T\raM ot <br />-Co;r1: (2 (9 (Q <br />Website (If applicable): Telephone: <br />h <br />Categories: <br />5 "Class A" (Direct Sales Only) $186 11] "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: c avie coo k e (( <br />Date: <br />1 % Z <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 />6. Water Source: <br />Please check what type of water source is being used at the CFO: <br />f2r-City Water E 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 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com