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SAN JOAQUIN <br /> <br />Environmental Health Department <br />Fp\ 002.3032_ <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />r \CO, a VW) OACSS <br />Date: 1 41,1015- Owner.plame: <br />0 LI-- <br />CFO Zip: <br />;A E-3C) <br />Cate ries: <br />"Class A" (Direct Sales Only) S186 0 "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 ALLI D 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 />('± ne s Nirne: <br />cYA4e toq i) tava <br />CFO Physical Address: <br />(L 1.0 V) <br />Website (If a plir: <br />CFO City: <br />Telephone: <br />irx-C <br />dog , L.901-77a <br />ckeco A-c-1. <br />C4\_y v <br />LcVaQ_ irt <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 />/eqse check w,bj type o water source is ting used at the CFO: <br />City Water `).1-6-11 c)., • El 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 1 209 468-3420 I F 209 464-0138 I w\A/w.sjcehd.com