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<br />SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />44r,'Xre?r Greatness grow: here. <br /> <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />1 CFO Business Name: ‘ Owner Name: , Date: 2 1 Z 9 <br />010A- \ a CY S V‘ f) ca--Ti YT1 f2)(“22- <br />CFO Physical Address: CFO City: 1 CFO Zip: <br />9-‘3 Foci- Donxiso el D Y • 64-or V+c)\'') Ca . 52J1 <br />Website (If applicable): elephone: .2o0( s 0-1 9 r <br />Categories: <br />[I] "Class A" (Direct Sales Only) $186 E "Class B" (Direct & Indirect Sales) $486 <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 L1 tAu.3 140nel eAx) <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 />Plp,se check what type of water source is being used at the CFO: <br />,n1 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.sjcehd.com <br />FRost-11-1030