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i c'- <br />z c\ SAN JOAQUIN <br />COUNTY <br />Greatness yrows here. <br />Environmental Health Department <br />.6 . <br />4,1„t:If 11, <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />„..—C) <br /> <br />FO Business Name: Owner Name: <br />i le Date: <br /> <br />—Rele3 j — 2e 2-fl <br />CFO Physical Address: CFO City: CFO Zip: <br />r-3 0_7-- V ( 0 (V\--- CA- . S-4-x ,c_g- i,r, v-3 eA- 495-c=3 <br />Website (If applicable): Telephone: <br />(\c-n.rA cib•7e). koo vtk q -2 2_ y3 7 <br />1. Categories: <br />E/... "Class A" (Direct Sales Only) $186 <br /> "Class B" (Direct & Indirect Sales) $486 <br />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 />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 Lis 0 0 0144__2__3 <br /> <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 />'City Water I] 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