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ni00S4-5-1 /MsL153 '33 <br />Environmental FREGE4veD1t <br />,..:5„ClU <br />411P. <br />,r SAN JOAQUIN <br />--couNTY <br />iSztor <br />Greatness grows hc <br />JAN 3 0 2025 <br />COTTAGE FOOD OPERATIONS (CFO) ENVIRONMENTAL HEALTH <br />-PERMIT/SERVICES REGISTRATION/PERMITTING RENEWAL FORm <br />CFO ausinessName: <br />CFO Physical Address: <br />2531°D -CPWYPA-E ttid <br />Website (If applicable): <br />OwnerIpmv)./e) <br />CFO City: <br />Telephone: <br />Date // 7/2,c <br />CFO Zip: <br />953 Le& <br />2-01- 32s <br />Categories: <br />"Class A" (Direct Sales Only) $186 )173c "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: Vii5 <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: stt 0-1-acked <br /> <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 />111 City Water XPrivate 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 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com