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e(LosLA -1-0k63 <br />SAN JOAQUIN Environmental Health Department <br />u ;.1 -h°c0C1.2.+01/4)0i8 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM \ <br />• <br />• <br />. • <br />CFO Business Name: Owner Name: Date: <br />MiNKY I.S frOGlIC NENI<I uLtAA c.iIc see <br />CFO Physical Address: CFO City: CFO Zip: <br />10.21 ficKErzfrio -i-krAcY 2)--11 50 <br />Website (If applicable): Telephone: <br />0 <br />, <br />0 "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 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: IVA \.(-:(c\Ieck, <br />rc6-S-S\5-1 —1•1•2`-1 <br />\c\Lmw-l-zkc. c6 -2s 03u) <br />fir\ok . C.ASYV\ <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 />0 City Water 0 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. Hazelton Avenue 1 Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />1. Categories: