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F(Lo <br />F-A- c.)0 2.--1 1B <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY — <br />V • C .nrcc q(c.110, 5 h <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />0 Business Name:Owner Name:L" . _ <br />I t-t- Q.' - R.f.,.._ 1(...L..c...k E rk-.._ 1/4., /Nc,-, 1- i 1r, 01. <br />CFO Physical Address: CFO City: <br />)co 7 I lf );_f-., r-1.,r) c_v. . <br />Website (If applicable): Telephone: <br />—<5 <br />Date: / <br />CFO Zip: <br />3 3 <br /> <br />Categories: <br />"Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: '1( 14 <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: <br />Ca kzs, t rYA,,se ;ns <br />T. 9)\e_rNN <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 />)iiity Water E 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 <br /> <br />r‘ • g...1 S[ZY)C-\.,Z51 <br /> <br />C)61--AgLr5 ‘ <br />