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SAN JOAQUIN <br />,-,t r I <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: Date: <br />6t1LeSC1 .rft) - I ce • 7-2fr <br />CFO Physical Address: CFO City: CFO Zip: <br />41-1 10:wood uN <br /> <br />VOCJ\A-0 c 141 °1620 -1 <br />Website (If applicable): Telephone: <br />0 1 00) sce3 <br /> <br />Categories: <br />E "Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: V 1\1 <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: C CA/1<_t r Wir (1C04-e s, c CGKe f 0 (O O<-! s ,19r01/61/Lir s- <br />cAtiocim ovloco\c\-vc ou\ °rid 1,-ps <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 />rfl City Water D 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 />WOSLilUIS