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ioae. ofrti'kte add <br /> l'ovt /q63132 7-3 <br />SAN JOilOUIN <br /> <br />Environmental Health Depau.ment <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name 1,, A e <br />CFO1Bhvsicai Address: <br /> <br />Owner Name <br /> .24) <br />Date: <br /> C?' <br />b —61-aq 6`C. <br /> <br />o City: <br />1)1/. <br />Telephone <br /> <br />Website (If applicable): <br /> <br />1. Categories: <br />-Class A" (Direct Sales Only) $186 <br />_ <br />,iik----- "Class B" (Direct & Indirect Sales) $4 <br />Prohibited Items: Initial if you agree to abide by the followin <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NS AL S WED. Only <br />foods that are defined as "non-potentially hazardous" are approved for preparation by a Cotta ood 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 />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 />City Water El 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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.corn <br />TV 091 1,-15kto S