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SANdOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />cz9 Business Na;.- Owner NgiA , <br />3Impt..(1g, I ne.. or ,, 1554/iii <br />Date: cit 1 .7 la3 <br />CFO Physical Ad ress: li CFO City: <br />1 ()nal r lop CA--. StDekturi, OA 6/6,49 <br />Weib <br />I -54(0 <br />isir (If applicable): Telephone: (0 4) 1.41 <br />N A- I <br />ate ories: <br />"Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the followi: <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 />I •""#- gur 1/..,a, / IL I,. <br />MERIMMIPMEREMT ,4_ <br />:a.(241 Staguttirti, <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 />Ple ies` e check what type of water source is being used at the CFO: <br />City Water E 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 1 209 468-3420 I F 209 464-0138 I www.sjcehd.com