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SAN JOAQUIN <br />pR 0 5 <br />Environmental Health Department <br />OLI N <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name Owner Name: Date: <br />CAKES r3 \I ANA) A('Jusi-Wr Oslosi <br />CFO Physical Address: CFO City: CFO Zip: <br />I 36 g S y F_tH PL rrouroTAlki 1--10cr 96.39/ <br />Website (If annlicab)e): Telephone: <br />-4-I sr 0.--/c6- e6sy <br /> <br />Categories: <br />"Class K (Direct Sales Only) $186 Ej "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: \I\O <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 />0-mized Co-kes Cur( ci,fre Coke, 1°010 5 <br />co-le esic les D ssed- cupc Sukco-y Cookres. <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 />6. 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 />6. 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 />e/(e;(es 752kT,