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eiz 0 S-1 593_ <br />F6. oc1-3- <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUN —Y ..,r. <br />r (7: <br /> Greo in ess q rows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner.Name: <br />crecitIo-02_ 413 igcal A-I I0an IQ <br />CFO Physical Address: CFO City: <br /> <br />LS (0 Li VNi CRTULt Dnve_, Lathrcf <br /> <br />Date: <br />q <br />ECaZ 0 <br /> <br />Website (If applicable): <br />.6T61:51e <br /> <br />1. Categories: <br /> <br />"Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: Q--2 <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: sugar coolcitS <br />Dcu,rm1W C041\k_. <br />U' ew a/it otppt C 1--LeAK <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 />01, <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />City Water LI 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 952051 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />-9 •5 c6 3 "a 2)