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} r i <br /> AR SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> -" 1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sicehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REG ISTRATIONIPERMITTING RENEWAL FORM <br /> CF Business Name: Owner Name, Date: <br /> _C70-P4147111 Address. CFO City: CFO Zip: <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) $146 ❑ "Class B" (Direct & Indirect Sales) $292 <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 fruit butters include a list <br /> of ingredients (attach separate page if needed). <br /> Food List: C) <br /> �+M­ <br /> 4642 AI ' <br /> Qd en tr <br /> A010, <br /> cn Ca 95212 <br /> n n don a <br /> "0. 11ou Coo i. C. �rmrl Y1y��rn County 4543 Barsarn Drive- • <br /> 4. Product Labeling: afaera' trio �fe �" j7 Trade in Harada, <br /> uaa � � •etr•d 4&;dle ame hp7� 95212 <br /> �oce447106w.-" <br /> rOb n•ag�0na Qh••f fl 4t �l x-00 deSCertlAlU023437 <br /> Attach two labels to this form for two o �g wtr+t. `'•_•.Hea ue•da•, C404-flu!hkChW dlP.il� <br /> r <br /> 0' tr�g•f <br /> Lift l,y.nlfa•o dlw'. : Wsnh <br /> product is made). . Idng. 1n. +.aa� <br /> 5. Water Source: <br /> um. r k <br /> www.huffalobak�ng <br /> Please check what type of water source is being used at the CFO: 209.7,51-91970-COM <br /> ❑ City Water % El Private Well* <br /> *If a private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> EHD 16-29 7127/17 1 CFO REGIPERMITTING RENEWAL FORM <br />