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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />4.2s2 Ezr,t Hcz.c!tcr, 0".vcr.uz. St:.',.s.!;tor., CA (..1.5.2.C5 6222. <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www 15jcehd corn <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />°1 OPZ3 <br />ACFO Business Nem Owner Name Date: <br />d AL fAML. --1-- SOCALC.t A otn.5A0 <br />CPO Zin <br />q•S• 4"/ 0Z <br />Wobsite (If applicable): <br />1. Cateqories: <br />-Class A" (Direct Sales Only) $125 D -Class 8" (Direct & Indirect Sales) $250 <br />I. !AI. .0 gm . a.. r /11110111,VI‘l itt$111.0. .• . 111.11.011 IS y uu otos au 'A... ti1J11.iti Lgy u mu 1,61.111a vg 1119. <br /> <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-borne illness. <br />3. F-'1uu'ut...i. <br />Provide a list of all products you are preparing. If preparing jams. jellies, or fruit butters include a list <br />of ingredients (attach separate page if needed). <br />Food List: <br />-(8ANA1'3A NA,UvTiN.5 <br />— NA ri% 0\03 <br /> <br />C1-10coLPk-T4 C..,AVAP CootAlE, <br /> <br />CFO Physical Address: <br />30.y4 CiLc, <br />CFO City: <br />D00)4.. <br />Telephone: <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required if only one <br />product is made). <br />Water Source: <br />r-tease crkecx wear type or water source is &mg owe at we GI-1J: <br />City Water 0 Private Well' <br />'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />END 15-29 5.19/2015 1 CFO REG/PERWITINORENEWAL FORM <br />