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Environmental Health Department Date: COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING RENEWAL FORM CFO Zip: SAN JOAQUIN ------COUNTY------ Greatness grows here. CFO Business Name: Owner Name: Tcffiovun kiMwi PamiK CFO Physical Address: CFO City: Z44OP N, cjgc-k TWc Pol f^carrypo CA- Website (If applicable): Telephone- _______________________ 21?^-7.24-4 1. Categories: pj' “Class A” (Direct Sales Only) $186 5. Water Source: Please check what type of water source is being used at the CFO: □ City Water Private Weir *lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) 6. Food Processor Course: Attach food handler certification for owner and each individual that were not submitted with initial application (including family members and/or employees). 1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com 4. Product Labeling: Attach two labels to this form for two of your CFO products (only one label is required if only one product is made). 2- Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as “non-potentially hazardous” are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food-bome illness. 3. Products: Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list of ingredients (attach separate page if needed). FoodList: froodc, &U.-Hercre6tnn fdrp&h Frui-VPvcS , Arppl-e^. z Jellies , Fn-ed Dru) exaking iwivfc,, |spice 4— □ "Class B” (Direct & Indirect Sales) $486 DtxiuFS, I vAtUfehmaUtAJS, Chpcol<i.bgd Covered Non pen shAJji-e Fbcd Galled Carbinol J, Priced Hof Cnotc>\aFc