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SAN JOAQUIN <br />COUNTY- <br />\L-L' <br />L-tt Stc„ <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Owr)9r Name,: <br />117_ <br />A CFO C>.. <br />filaAh'4/ ry <br />Telephone: g ()-41 <br />Date. „I-7 7-1V <br />CFO Zip: <br />95-1 77 <br />CFO Bus)r)ess Name: <br />N j 4Ifey <br />CFO Physical Address: <br />Website (If applicable): Y4'5' <br />Categories: <br />"Class A" (Direct Sales Only) $186 LII "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: tJt <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). SC-- <br />Food List: \ <br />5---c-AfJfki111 /4,6' Q y (.2 (e3 <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 />S.-City Water 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 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com