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Environmental Health Department <br />Date <br />c--; , C <br />r- <br />'t- <br />^2-SqC)^52 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />SANJOAOUIN <br />------COUN~ ------ <br />G -1'3 t l 5 ;• 0 <'O A 7 t •' *. <br />1. Categories: <br />J/fx “Class A" (Direct Sales Only) $186 <br />5. Water Source: <br />Please check what type of water source is being used at the CFO <br />Water Private Weir <br />*lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <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 />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 I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />s//3,^ <br />CFO Zip: <br />,y’ Owner Name <br />CFO City: <br />| | "Class B” (Direct & Indirect Sales) $486 <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 />Telephony. <br />CFO Business Name'^ <br />CFO Physical Address. <br />/yr) fg Q t4- <br />Website (^a^pli^able): <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 />/