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SAN JOAQUIN a <br />PQ. <br />Environmental Health Department <br />COUNTY— <br />Grecioess qtrnArt heir <br />CFO Business Name: <br /> 1-71;101( )-„J° d.r,v, <br />CFO Physical Address: <br />Owner Name. <br />\At;Iet NiOttr <br />CFO Cil0- CFO Zip: <br />Date: <br />ors <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Website (If applicable): Telephone: <br />'5 to-55 1 3 <br />Categories: <br />11 "Class A" (Direct Sales Only) $186 n "Class B" (Direct & Indirect Sales) $486 <br />2. 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: <br />Cckice s <br />V>-‘e_sra 4P1 <br />e- <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 />17"City Water <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 1 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />Water Source: <br />Please check what type of water source is being used at the CFO. <br />11 Private Well.