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• <br />SAN40A0"1 <br />F/I 0°3_2 645- <br />,ita fis-F.Ath Denartmsrr'r <br />PR 0539 5 3`1 <br /> <br />C U <br /> <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Owner Name: Date: <br />CFO Physical Addre <br />cA0 ?4_ \st,D -7f ••2 ‘i•\*(1 c\)\C)\\C)a•L CFO City: CFO Zip: <br />Website (If applicable): Telephone: <br />c;,,y z..ekoo,ey (-,,,uiccx.cA. we\ ca.° ct) cA.1 <br />Categories: <br />U----"Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $486 <br />2. 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 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 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 />\,3 -r-A5.>1\isoos <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 made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />g-6ity Water n 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 />1568 E. Hazelton Avenue I Stockton. California 95205 l T 209 468-3420 I F 209 464-0138 www.sjcehd.com <br />CFO Business Name: