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LLI,LL-e (--,1:k..cca1a.tLy) <br />' <br />r)(4Ke. <br />PR OCLi ES18 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name:• Owner Name: , . <br />(C <br />- <br />1(9 L_ c,h cr\s <br /> <br />k-2e171-) ns <br />Date: <br />/2 - <br /> <br />CFO Physical Address: CFO City: <br />jini 21) ./11.2/7 ./eck <br /> <br />CFO Zip- <br />Cif-I:33 6,-, <br /> <br />Website (If applicable): Telephone: 2 6 `i? <br />Categories: <br /> "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: <br />- <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 />3. Products: <br />Provide a list of all products you are preparing <br />ingredients (attach separate page if needed). <br />Food List: Cc:0<e 5 , Li\xj(0 <br />(-)c., r • /4; d ()L <br />Cif( c!-k. (1)- jiff p1(-J2eic <br />If preparing jams, jellies, or fruit butters include a list of <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 />yt City Water E 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 F 209 464-0138 I www sicehd.corn