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Date: <br />MtchcilC/ <br />(LA <br />□ “Class B" (Direct & Indirect Sales) $486 <br />CFO: <br />'OrtzuiS COf&s^ <br />‘Vie.G___________ <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />, <TA. <br />l o /1 I i-( <br />Environmental Health Department <br />1. Categories: <br />[V “Class A" (Direct Sales Only) $186 <br />____ <br />Cookies <br />SC-one. S_____ <br />'Bo-rs <br />5. Water Source: <br />Please check what type of water source is being used at th? <br />□ City Water S'Private Well* <br />*lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /><0/^ <br />CFO Zip: <br />^93fc>A <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 1 F 209 464-0138 | www.sjcehd.com <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: <br />one label is required if only one product is <br />SAN JOAQUIN <br />COUNTY <br />Greatness grows here <br />4. Product Labeling: <br />Attachlabels to this form for two of your CFO products (only <br />made), r <br />CFO Business Name; <br />CFO Physical Address: <br />____17035 &• AAi\g <br />Website (If applicable): <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 />Owner Name: <br />FtLTrr>S D o-lc una <br />CFO City? <br />cd ijpon <br />Telephone: „ ,a.oq tpia 4~ig^