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SAN., JOAQUIN Environmental Health Department <br /> —COUNTY- <br /> - Grratnrss groos bore. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO busi11n��ess Name: <br /> T n eT S Owner Name: Gax <br /> r <br /> crKe-y+j Ta��-�- flsel —Vqysu <br /> CFO Physical Address. CFO City. CFO 25p: <br /> X96 Bv4+1,alc Lottie- S {+DCOVM Cg 99JLO6 <br /> Website(Ir applicable): Tetephone: <br /> Slobe9�(F�9 <br /> 1. Categories: <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 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 /> Fppood List: <br /> lrvi c B rest <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 certication for owner and each individual that were not submitted with initial aopiication <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.sicehd.com <br /> Scanned with CamScanner <br />