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SAN J Q A Q U I N Environmental Healt111Dq rtment <br /> —COUN <br /> Greatness grows here. APR <br /> �'Nv/40N� �? 24 <br /> COTTAGE <br /> COTTAGE FOOD OPERATION— <br /> REGISTRATION/PERMITTING RENEWAL FORM �t�FNTEq��h <br /> CFO Business Name: Owner Name: Date: <br /> 0or7m utero UoJa 3�3 I <br /> CFO Physical Address: CFO City: CFO Zip: <br /> )F)56 �e o OK. fA533c� <br /> Website(If applicable): Telephone: <br /> 5�- <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only)$186 ( "Class B" (Direct& 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 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 /> 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: LerrnDjr) <br /> fxe0z_-bIf4�4b Scone; <br /> - ��.01 E r' f S� l' aC,Chi <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: <br /> City Water ❑ Private Well* <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. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />