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SANIOAQUIN 4 , " —COUNTY-- <br />Greatness grows here. <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: CULEBRA COFFEE Owner Name: ITZCOATL FRIAZ <br /> Date: <br />9/17/1998 <br />CFO Physical Address: CFO City: CFO Zip: <br />9143 BLUE FOX WAY STOCKTON <br /> <br />95209 <br />Website (If applicable): Telephone: <br />CULEBRACOFFEE.COM 209-482-5342 <br />Categories: <br />IX "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: <br />71 ""'"" <br />Initial if you agree to abide by the following: /f <br /> <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 />ROASTED ORGANIC WHOLE BEAN COFFEE <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 />R/City Water El 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