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P <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY — <br />„Jrcatness CVO W <br />COTTAGE FOuD OPERATIONS (CF u) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Buqiness Name: A Owner Na.rne: <br />\)13Shor-itorfaci cooGis e Di;t 5/0).0_2 <br />CFO Physical Address: CFO City: <br />Llokid 'Thar- s-17,GL <br />Website (If applicabl ): <br /> <br />CFO Zip: <br />96:2040 <br /> <br />90 93F--3.00R' <br /> <br />Categories: <br />0 'Class A” (Direct Sales Only) $186 <br /> vi "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: Fl/.6 <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 />Food List: _If) Deftrea6 Coo S <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 />IX 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 1 209 468-3420 I F 209 464-0138 I www.sjcehd.com