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1 SO <br />Environmental Health Department <br />I <br />I <br />1 <br />If preparing jams, jellies, or fruit butters include a list ofI <br />l <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />SAN JOAQUIN <br />COUNTv <br />CFO Zip <br />qesvk__ <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 />5. Water Source: <br />Please check what type of water source is being used at the CFO <br />^^City Water Private Well* <br />‘If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results ) <br />1. Categories: <br />"Class A" (Direct Sales Only) S186 <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 />3. Products: <br />Provide a list of all products you are preparing <br />ingredients (attach separate page if needed) <br />Food List <br />\ m V, C-U p - <br />f-gky uJi-Ha jCroshng oc -bop, ^ccon OavueA <br />an A CV\oc,d vaW, oriAop, OcopeA <br />Chip and adA taG. btPPeA m CViocdate. <br />4. PmM:rodS ChoclaH <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 /> “Class B" (Direct & Indirect Sales) S486 <br />CFO Easiness Name Owner Name <br />pewie s. CaVepops_w\A Suoeev- <br />CFO Physical Address i CFO City <br />I S'2/? _'Tr<i C^l_z <br />Website (If applicable) Telephone J , -» r- .