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SAN JOAQUIN <br />—COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />Red vood Tect Eg+q4e., <br />CFO Physical Address: <br />547‘i StAhry Roaci <br />Website (If applicable): <br /> <br />Owner Name: <br />Pcrftick. Sum bury <br />CFO City: <br /> <br />Date: <br />IN/ 2-9 <br />CFO Zip: <br />1 SZ1 <br /> <br />Telephone. 4) 6(_2.03... <br /> <br />1. Categories: <br />1X1 "Class A" (Direct Sales Only) $186 0 "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 List: le ot C c 1,1 eithi sii) Dri.e4 <br />Koitbt4h L (43c, c% iforaco, — Dried • <br />(AA 1/1÷k 4.% rifef:tc) --- Dried <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 />0 City Water x'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). }Jo New members/ etnrIpyik s <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />05i-1 )1-2(