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SAN J O A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATIONWERMITTING RENEWAL FORM <br /> N--jr-1(�C ?BUSF e��b1/� O+mer Name S Datc ` <br /> 1—t <br /> FO Phy t(al Nldr s CFO CFO Zip ^ ^ 4 <br /> at�ar6_ �+ <br /> Web sd (If�applr:able) Ielephorw ,,/� �J J 2A 5 Q <br /> �� /r1_YI\ - I - --- <br /> 1. Categories: <br /> -Class A'(Direct Sales Only)$186 ❑ 'Class B'(Direct 8 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 1 ED Only <br /> foods that are defined as'non-potentially hazardous' are approved for preparation by a Cotlage Food Operation <br /> These foods Include Items that do not require refrigeration to keep them safe from baclenal growth that could be a <br /> cause of food-bome Illness. <br /> 3. 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 /> s <br /> �w <br /> (A �Cx r\-9� -�wZ-� C��mo�;.1 . coyy) <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 /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: (J"" L ✓1 �� <br /> [�Clty Water ElPdvale Well' "� p�, (� l G <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 Haiellon Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www s)cehd corn <br /> C <br />