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S A N J OA Q U I N Environmental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Name: Owner ame: p te: <br /> '60d 1 I� 204 <br /> CFO Physkaf Address: CFO City: CFO Zip; <br /> Websile(if applic le): Telephone: <br /> V&JuCAafflrietDiqis ad <br /> 1. Categories: <br /> ❑ "Class A"(Direct Sales Only) $186 [ , "Class B" (Direct&Indirect Sales)$486 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: U_ <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 refigeration 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 butlers include a list of <br /> ingredients (attach separate page if needed). <br /> Food List; , <br /> � � la�l�lb�l25 <br /> � 2zZs <br /> 2-� <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 /> rity Water ElPrivate Well' <br /> fa rivate well,attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: <br /> Attach food handier 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 />