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SAN JOAQUIN <br />N1-1 <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: <br />44644ilL A <br />CFO Physical Adams. <br />L <br />'t1.1 rrt.,sesta, r ea PI ..f 1. a <br /> — <br />Website (If applicabha): Telephone: <br />(94,4 Date: --ifs/43,A De/i .,de,) <br />CFO City: CFO Zip: <br />thz-PL-G-0 <br />(2.4-4--c„ ciat <br />;G.—X.. era, r riy .51/1 C41.- C 0 <br />Food List: <br />00-2- s--0,z740 <br />Categories: <br />DKI 'Class A- (Direct Sales Only) $186 111 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited items: Initial if you agree to abide by the following: <br />Foods containing 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 ail products you are preparing. If preparing jams, jellies, or fruit butters include a list of <br />ingredients (attach separate page if needed). <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 />Please check what type of water source is being used at the CFO: <br />IN City Water EI 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 />1668 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I \,vww.sjcehd.com <br />