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3 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, StocktonCA, <br />a Telephone: (209) 468-3420 Fax: (209) 464-0138 W 95205-65232 <br />eb: wvnv sic_ eh <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />dlnPls7lr�pnll� Owner Name: <br />CFO Physical Address t ISv `C <br />FD, n 111:7`0 City <br />Websrt ,( apphoable) I ( I-gfitnt�o._ Gh33�j <br />1. Categories <br />.,Class A" (Direct Sales Only) $125 <br />2. Prohibited Items: <br />❑ "Class B" (Direct 8 Indirect Sales) $250 <br />Initial if you agree to abide by the following: L �_l <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a 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 <br />of ingredients (attach separate page if needed). <br />Food List: . <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 <br />product is made). <br />5. Water Source: <br />Please check what type of water source is being used at the CFO: <br />(?City Water <br />❑ Private Well` <br />If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />RD 16-29 6/29no15 <br />!7 <br />CFO REG/PERMITTING RENEWAL FORM <br />