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P2-0s,-1 ---� �0 <br /> SAN J OA Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Nan,e :�.Vnrr?..)rnE• Date <br /> a ,S 72SS�jr�s 0h4k1ied 4botisC1Pn-g 9 J)-'14 2- ZDV y <br /> CFS O Physical Address FFG C,:, r_ CFO Zit <br /> 7ZI DL4hCith r• IPq� - CA • 9' 37 <br /> N,eGsite lit applicable, Tepho,,e <br /> ---- -- __ Yy3 - 2-2_ 0 - �lg( L <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $186 -Class B (Direct & Indirect Sales) S486 <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 Mems 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 reeded) <br /> Food List: <br /> l _ _b yr,a k i her Yn i ec,��-pr',,� o�e�s s ,ejr a <br /> yl h5 S SLA CJAn G S ILS YV4 G q n of �' 1 A <br /> at'sSVP-%C%x* Yl� (-xhsis & IVWr Sw94,r,Sill 3-, <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if onIv one product is <br /> made). <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO <br /> 4, <br /> 12- C Water ❑ Private Well' <br /> 'If a private well. attach all updated water sample results Including quarterly bacteria and Nit,ate 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 /> S <br />