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PR 0s4 3 75--7 <br />SAN J OA Q U I N Environmental Health Department <br />RECEIVE <br />JAN 2 1 2022 <br />COTTAGE FOOD OPERATIONS (CFO) ��,tl����icNTIiG;II 'itl <br />REGISTRATION/PERMITTING RENEWAL FORM DLPI(.L <br />AL <br />C;F)O_ Business Name: Owner arae: Date: <br />�C�GE n ppe"er�res ULml Jj M,2. , <br />CFO Physical Address: CFO Cit : CFO Zip: <br />(:?,5D-? VEA ( 0 M l an qss, 6(0 <br />Website (If applicable): Telephone: <br />1. Categories: — <br />❑ "Class A" (Direct Sales Only) $155 [ n A "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: OIL <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-bome illness. <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 />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). Orn!, Use, l k G.bL, <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />❑ City Water ;91'�rivate Well" <br />'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />60 <br />