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SAN JOAQUIN Environmental Health Department <br />CO UN <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: ,Owner Name: <br />\C <br />Date: <br />v\r,2);\0\ vss, \\\Ltj <br /> 2_ <br />CFO Physical Address: <br />\tit. <br />Website (If applicable): <br /> <br />CFO City: <br />cc 'IN\O'ot <br />Telephone: <br />- al. • 2. -7S- <br />CFO Zip: <br />25-31 <br /> <br />Categories: <br />"Class A" (Direct Sales Only) $186 ''Class Er (Direct & Indirect Sales) $312 <br />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-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: <br />0- c <br />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 />Water Source: <br />Please check what type of water source is being used at the CFO: <br />LI 'City Water El 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