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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />V C4.0 (A CD rt-rec.linas Sa. geAict .‘ L ti3 /23 <br />CFO Physical Address: CFO City: CFO Zip: <br />8 5\ CriAr),-e_r, .SA-ret,4 SA-ock-A-ori ctS'20 9 <br />Website (If applicable): Telephone: <br />(209) 599-9361 <br />Categories: <br />Vi "Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: kic <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 Lis t.Q.c3oVi.as , brouor.i es, biNr‘dieS) rActuAt-orvs, cake- Foes <br />Product Labeling: <br />Attach one label 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 the CFO: <br />t City Water LI Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />Food Processor Course: 44-4cjie1 L1/4_3 4.1,\ VA5.0-1- <br />Attach food 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 1 209 468-3420 I F 209 464-0138 www.sigov.orgiehd