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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />cs, <br />Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Busines Na e: e: <br />\AL cike w+-e, CA ke <br />CFO Physical Address: <br />t E. Fronf 5+; <br /> <br />Owner Name: <br />0 X4 lernOt. niAr Date: <br />CFO City: CFO Zip: <br />Lrokr) 9529)6 <br />Telephone. <br />(tZ OGI ) 900 -2”0 <br /> <br />Website (If applicable): <br /> <br />Categories: <br />"Class A" (Direct Sales Only) $186 Ej "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: X (Vi <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 />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: C , tiNt 1:),4tenrearel C4 pCct Py4-1--erc awl-) Cooke5 <br />Iv cioworv5 w rcrinvv1 )14-e Pops ) Cok Be I <br />Product Labeling: <br />Attach one label to this form for one of your CFO products (only one label is required if only one product is <br />made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />ACity Water 111 Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/EHD