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c7ROSL\ 53 <br />- <br />SAN JOAQUIN <br /> Environmental Health Department <br />COUNTY — <br />,...,rttnoss grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name. Owner Name: - Date: <br />n t I Off— 12.0ad 1-3ar o Jilt& gd6ei( cf, .- 211 <br />CFO Physical Address: . CFO City: CFO Zip: <br />2 22 - ir EA/Off- ed- )00.7) IT) p) , 0-P4 (4276) <br />Telephon: 6?..., 1.40 Ito .....3_ sq2g, <br />Categories: <br />,acr .Class A" (Direct Sales Only) $186 ci "Class B" (Direct & Indirect Sales) $486 <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 (A4OWED. 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, o <br />ingredients (attach separate page if needed). <br />Food List: pc r e c; <br />CJ4.Qi irt4 i.rrL,1 <br />e a myna omrn, .61 VC red nu <br />r fruit butters include a list of <br /> <br />rt) <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 />fl 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 T 209 468-3420 I F 209 464-0138 I wvvw.sjcehd.com <br />Website (If applicable):