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SAN J O A Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING <br /> 1�RENEWAL <br /> '1 FORM <br /> J D <br /> Business Narne: O%mr Nam: ate: <br /> in 77 <br /> - npkK DA F:14 <br /> CFO rPrh—y1siic�al Address: CFO City, � CFO Zip: <br /> Website(if applicable): Telephone: <br /> 57 i ire (tie �� �.car� 9.M 32-7 -MTOe"I 327. 0 01 <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only)$155 "Class 8"(Direct&Indirect Sales)$310 <br /> rN <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 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 /> G('\'4� ('CS vyw_, <br /> _FIZVS cd -am u-�Ao oar ¢ c-E 'moi cel t1�d�a <br /> cwp�a.c4s <br /> cis <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). <br /> 5. Water Source: <br /> Please check what type 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 />