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..114r.c.c114. <br />SAN JOAQUIN <br />—COUNTY— <br />Greatness growl herc <br />Tr-(2k oo 2\00(0 -3 <br />Environmental Health Department <br />PR osk_i Oct <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: <br />CJ 16 Qa 0/1AVVZ111 V. ,(901(da <br />CFO CT y: <br />.1k 14u *oc401 g/OQ-9/(i <br /> <br />DaNX/ 1904- <br />CFO Physical Address <br />43 (),A oro <br /> <br />CFO Zip: <br /> <br />VVebsite (If applicable): Telephonem <br />Categories: <br />"Class A" (Direct Sales Only) $186 [1 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following:LY <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 />OalW ids <br /> <br />Ckjc(cAy.c.A-NQ-r(j jc\VN00 C_OeM^N <br /> <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required if only Pailiglirr <br />made). RECEIVED <br />Water Source: AUG 26 2024 <br />Please-check what type of water source is being used at the CFO: SAN JOAQUIN COUNTY <br />City Water L Private Well* ENVIRONMENTAL <br />HEALTH DEPARTMENT <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