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1» <br />Environmental Health Department <br />"Class B” (Direct & Indirect Sales) $486 <br />SAN JOAQUIN <br />COUNTY- <br />j?) srAiQtxv. hunekl <br />CFO Business Name: <br />UW, iaIoX <br />CFO Physical Address: <br />Ho 2-7 1amWk Lwt <br />Website (If applicable): <br />Owner Name: <br />fltna (Mas <br />CFO City: <br />Wi/ C,4. <br />Tejephone:(ui) <br />one label is required if only one product is <br />1. Categories: <br />“Class A” (Direct Sales Only) $186 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />4. Product Labeling: <br />Attach two labels to this form for two of your CFO products (only <br />made). <br />Date: . > <br />2>(s> <br />CFO Zip: <br />^57^ <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: z. <br />__All OfftMer <br />__C-ornstarch, butfeir, wmV&voiai <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 />cause of foodTirne illnes^31 001 refrigeration to keep them safe from bacterial growth that could be a <br />5. Water Source: <br />Please check what type of water source Is being used at the CFO: <br />M Clty Water □ Private Well* <br />*lf 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 | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />arm Du-ttev-, \nWR sugar, honevl <br />Wih paste, Wi( - sMert cnip5, <br />lAVPQllmS, YWA( \Xv-ftV\am e-fflVYVA 1