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/'R Osyy 3194 <br /> SANJOAQU ( N Environmental Health Department <br /> —COU N-Y -- <br /> ,,OTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner Name: _. <br /> MLA-6 VOIA Aftx (ns*a. <br /> CFO Physical Address: CFO City: CFO Zip:nG <br /> y tk -M;rd " <br /> �4. �?an <br /> Nebsite(If applicable): A 11 / Telephone: / r'10A)Li <br /> 6A—h c< <br /> 1. Categories. tV f1 �pCv J—1 !J1/ W��p <br /> ❑ "Class A" (Direct Sales Only) $155 "Class B" (Direct & Indirect Sales) $310 <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. 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 _- <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 it neeot-. <br /> Food Lis_. :PIawieA WMV\Lkt5 <br /> a. Product Labelina: <br /> attach two labels to this form for two of your CFO products (only one label is required if only one product is <br /> mac- <br /> 5. Water Source: <br /> Please check what tvpe of water source is being used at the CFO: <br /> City 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 /> 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 /> S <br />