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S A N J O A Q U f N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name. Owne1r game: D•to <br /> ado -�Cd <br /> CFO Physical Address I CFO City I _ CFO Zip: <br /> �P� 1—lait7 11nL{rT ��(ZC'� �'�C�LTU1� PA r�vri <br /> Website(If applic le): Telephone: <br /> 1. Categories: <br /> ❑ `Class A' (Direct Sales Only) $186 [ 4 "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 <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 /> 3. 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 /> r`rer � Q 1 b�125 <br /> � 2225 <br /> 2 2-5 <br /> 4. 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 /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> ity Water ❑ Private Well' <br /> fa private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> 6. 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />