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P£2SOOIO$ <br />»' <br />Environmental Health Department <br />Date <br /> “Class B" (Direct & Indirect Sales) 5486 <br />6 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />SAN JOAQUIN <br />COUNTY <br />2. Prohibited Items: Initial if you agree to abide by the followinq^SX ^ <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 />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 />dty Water Private Weir <br />•If a private well, attach all updated water sample results (including quarterly bacteria and N.trate results.) <br />1. Categories: <br />"Class A" (Direct Sales Only) S186 <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 />Foocl List Oandu_____________ <br />_____rYTn #~6h rvigl..|_______________________ <br />CFO Zip <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 | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www sjcehd com <br />CFO Business Name —,— , V Owner Name <br />____ ______z, <br />CFO Physical Address CFO City <br />fclue. OaY-L.o ( OlThidP______ <br />Website (If applicable) Telephone xr-cT"________ ______________H ' n I o "