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FRDst-ilLISO <br />SAN JOAQUIN <br />COUNTY— <br />Greatness 9rows here. <br />Environmental Health Department Tjt <br />copy <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CF0ness Name: <br />rek-wh.. 6r)iirrNan r koey. Date: .7-- <br />CFO PhY ic)A4ess: 0 10 EN <br />CFO City: <br />ige44— 4Fr? <br />Website (If applicable): Telephone: <br />z_oej <br />Categories: <br />El "Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the followi <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are OT LOWED. MI ly <br />foods that are defined as "non-potentially hazardous" are approved for preparation by a Co age Food Operation. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth4hat 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 />Ala 1-111-1 My'dwh RECEIVED <br />JAN 16 2024 <br />ENVIRONMENTAL HEALTH <br />1) EPA RTNI ENT <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 />I ase check what type of water source is being used at the CFO: <br />City 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