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SAN JOAQUIN Environmental Health Department <br />—COUNTY— <br />°, <br />Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />C 0 Business Name: Owner Name: Date: <br />GiZtE`s Rtes C)VV0t?_Le SEGLt%f2 S—Z—zozz <br />CFO Physical Address: CFO City: CFO Zip: <br />l 4'7 <br />I Al Tr e,i-heWar V� 6L-V_e Gy-cA 'R,S Z37 <br />Website (If applicable): Telephone: <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: L� <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 -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 of <br />ingredients (attach separate page if needed). <br />Food List: <br />• r M <br />4. Product Labeling: <br />Attach two labels to this form for two of your CFI JA <br />made). <br />Ctierie's (Pies <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />❑ City Water Private Well* <br />Cherie Segler <br />17971 N Tretheway Rd <br />Lockeford, Ca 95237 <br />Ingredients: Unbleached flour(Wneat flour, nladn,raduced Iron, <br />Thiamine, mononitrate, riboflavin, and folic add). Fruit, Sugar, <br />Vegetable shortening, Cornstarch, Salt, Cinnamon, Nuhneg <br />Conine: Wheat <br />Made In A Home Kitchen <br />Permit#PT0025226 <br />Issued In San Joaquin County <br />Net Wt 2.51bs (40.0 oz <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.sjoehd.com <br />