Laserfiche WebLink
SAN JOAOUIN Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name. Owner Name Dale <br />IFL6 B12EAD,ut. i(eylN 6(Q61`JL 01-09- 23 <br />CFO Physical Address CFO City CFO Zip. <br />Q61 WIN.IAIhSer Rn MANTECA _ y5,531 <br />Website (if applicable) Telephone <br />KEW RQEAG.tei," 1,214 - T? f -Ipfyr <br />1. Categories: <br />® "Class A" (Direct Sales Only) $155 ❑ "Class B' (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: K(o_ <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br />foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food Operation. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br />cause of food-bome Illness. <br />3. Products: <br />Provide a list of all products you are preparing, If preparing jams, jellies, or fruit butters include a list of <br />ingredients (attach separate page if needed). <br />Food List:• <br />'' wanrl <br />unCA1 <br />d f/ " <br />�OU."y <br />L.A.""- <br />{Loup r <br />WATIf4 BAIT, secop c-t8i 'fy •Maud LvAT e'a SArlr <br />Faw.1/kff. SLte f SvNf••w <br />Cl SE617 <br />r$ AMl. <br />FL AY y Nr d lr",# IrerkeJf c4eAGCE0 &e, � lVho CW, ffM �r <br />WHCA9 rf—d I 1,114VII!f <br />t40 SCIA-*,%SMP <br />N <br />110AL4110-4YAN19Ek0Y "CAr Ill'rn!f��r <br />NkLNWS, Witty 046900W. <br />"eye �- <br />Ng6h1 FL -W, {eye-Ft..K r f+ATrf>t, SRc7_ V SPECT �r <br />WgCTH I'Lwu WR7 <br />EKf SALT <br />. eINNA MGM (Telt} wnI:A1 1'(.VQ{ wk� �oCONy 0(l,r J.Yr <br />r <br />G AS MtdS , ivG/k✓Lf Sh LII <br />C•rf ,VAwt Nr <br />oRLrNG61&5-f 01"Almy Mp"41rp� BRew NAnp <br />4. Product Labeling: yCltoW µvlTtdp rerwsfA"L¢c,V5A VINEGAd, s41_r, <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' Le Revta5E o6r40V.f <br />ff?.M 1181`6 V4U719laEWAT[a 4 <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 952051 T 209 468-34201 F 209 464-0138 1 www slcehd com <br />