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Pcos -nsci <br />FP\- 0o2_\0 -1 S(8, <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUN —v <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />9 O Business Name: Owner Nome: <br />6 rd\r-6<.-VV IC,C/-i6 K-rio-VC) 6 ()Aktr) <br />CFO Physical Address: CFO City: <br />r(51 OVU}SikOrPr. <br />Website (If applicable): Telephone: ZO q (gc9(9-75- <br />1. Categories: <br /> <br />p;9 "Class A" (Direct Sales Only) $186 111 "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: (uiw-coe, u_c\or. (-C o on <br />evto(w(e 616 , Oyç cobK,s <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 />IXCity Water 1=1 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