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<br />SAN JOAQUIN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name. <br />0 rOYVS-Tee 3tk.6(11 Co. D o\e-0,yckA <br />CFO Physical Address CFO City. <br />'1 O4 'JAW \Na,v) <br />Web-site (If applicable). Telephone: <br />Ad Ck_ 12/01°1 . 1-40 9)- l,Q LH <br />Date <br /> <br />Categories: <br />15- "Class A" (Direct Sales Only) $186 Ill "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: iPlik) <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 />Q.A)R-CL1 C.C5i6CS, CkOCAC Al9Fed cieekA•e,s(pf-ti-5. <br />oo,)cc-1 rice, DripitS <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 />le City Water El Private Well* <br />*lf 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 <br />PQ091i2-4y <br />Food List: