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COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Jsmep Name: <br />k � V Owner Name: Date: <br />CFO Physical Address: <br />c15 3 a <br />Website (if � �{rable): <br />(i <br />1. Cate orieS. <br />"Class A" (Direct Sales Only) $155 <br />2. Prohibited Items: <br />I ry <br />City: <br />Tra <br />Telephone: 1 <br />(:9C)S--cel <br />CFO Zip: <br />Of S-5 _T q <br />❑ "Class B" (Direct & Indirect Sales) $310 <br />Initial if you agree to abide by the following: <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. On <br />foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food Operatiol <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be <br />cause of food-bome illness. <br />K.t_ <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 />C6-12�co , LDO kaes <br />v rl cp- (� <br />b6)et- <br />Ch o(_ Av .{e 0_e <br />C <br />o r�C) e:h cy , l a l e <br />)Y_r✓cV1ZV <br />4. Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required <br />made). if only one product is <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />;316`rty Water ❑ Private Well - <br />If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results. <br />6. Food Processor Course: ) <br />ler <br />ion <br />r owner and <br />(includ ng amttach food il ymembers atnd/oroemp oyees). each individual that were not submitted With initial applicatio <br />n <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwwsjcehd.co / <br />m <br />