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,••• <br />SAN ,JOAQUIN <br />COUNTY— <br />Grcotness grows herc. <br />7tr, C <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: . Owner Name: k <br />NI'MI mud tvT11.1-tt-KR, f-augtib <br />CFO Physical Address: CFO City: <br />iknQiir tChn j1).CA41\ll <br /> <br />Date: <br />I 312 c <br />CFO Zip: olcs-2 <br /> <br />Website (If applicable): Telephone: <br /> <br />Categories: <br />-Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: <br />Foods <br />- <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: No. (c,Q jdfo yitk 1i4DIJ ut,e,,jfjj <br />(-0/?6di, ctuK-it3 v\kal[LI \,0e4it 406ds <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 />ik 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. Hazeiton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.c,om