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OS- <br /> SAN <br /> SSAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> RE/�GII�STRATION/PER//M/)IIT/TINNG RENEWAL FORM <br /> �OTusines0191Name:A f'IUI ��50wmrNonIIIA /t //y Date/a_// /J/� <br /> . /�1-3ppllT3�(�n(�(j1([ TTfflrff((��( DODw�QD FO tib N ✓ KIV///TSCA 5337aO1 <br /> Webslte(if apPlicable): Telephone: '/O J �g6 rCXo�✓✓ <br /> 1. Categories: of <br /> X"Class A"(Direct Sales Only)$186 ❑ "Class B"(Direct&Indirect Sales)$312 <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 /> Q 'OV� S f ,110 0� <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 /> Ity Water ❑ Private Well" <br /> f 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.sjgov.org/EHD <br /> S <br />