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i <br /> 2-'-Aoo20 <br /> S A N 1 O A Q U I N Environmental Health Department <br /> COUNTN <br /> (;rratnrsi gr��ws hrr, _ <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name Ow er Nartta: aonfrw khi he/oLia tj- Date: <br /> -;�> Gq(3RiEtGE �Lrwtcf}� - <br /> CFO Physical Add+p�t; CFO City: CFO Zip: <br /> /-U7 7 '/Y SYUn Or. 794CY 9-t377 - <br /> Webs"(Mawscstoet: Telephone: <br /> 1. Categories: <br /> R "Class A- (Direct Sales Only) $186 ❑ "Class B° (Direct& Indirect Sales) $486 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: CA' 64' <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-bome illness. <br /> 3. 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: CQp��� CsIpCAKES� T T <br /> 4. 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 /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO. <br /> O'City Water ❑ Private Well, <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. Hazeiton Avenue I Stockton, Califurnia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd com <br />