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a"4vl 's SAN JOAQUIN COUNTY <br /> r' a. <br /> k ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> rttiiAaa�`1F Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sogov.brq/ehd <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM r <br /> CFO Business Name: �1 �Q � Date: <br /> CFO Physi al Address: dC 1 CFO City: CFO Zip: <br /> Website(If applicable: Telephone: _ _ �- <br /> I � �(- (I < l <br /> 1. Categories: <br /> x "Class A" (Direct Sales Only) $125 ❑ "Class B" (Direct& Indirect Sales)$250 (� <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. <br /> Only foods that are defined as "non-potentially hazardous'are approved for preparation by a Cottage Food <br /> Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or nut butters include a list <br /> of ingredients(attach separate page if needed). <br /> Food List: <br /> i4 <br /> 4642 Moatb rDelve-Mots&&[a 95212 �l for two of our CFO products(onlyone label is f642 MOehoa-°-`,"C.n tee eszlz • <br /> Made in e llKitchen' y quin County <br /> 12 Cwlud 'bindc iv a home Kitchen' <br /> Ingredients: 12 Cookies <br /> Cmtlr:Cmnr,agar,become,rdg,liked poadar,Carving. Cookie Ingredients: <br /> Icing:omhotlenme'a awn atanh,dried t% Oatmeal,flow,brown aurin,whit.eugu,bunco,Ogg,, <br /> ahoam.gna=1 <br /> l0,=in of barer.. t, coconut,baking powder,baking soda,vanilla.salt. <br /> Lanced..da dvae.vnfl.lal na=. <br /> ,of water source is being used at the CFO: <br /> er tc.buil'alnhakilwcv.cum :buf[alobakin co.com <br /> 4�frVrivate Well <br /> elf a private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> EHD 16-29 1/23/14 1 CFO REG/PERMITTING RENEWAL FORM <br />