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I►w <br />19 <br />SAN JOAQUIN Environmental Health Di <br />trn <br />r <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />^'O Business Name: Omer Name: Dat <br />CFO Physical Address: k&O City: CFO Zip: <br />�S l� G;imv-\Q- - c s <br />Website (If applicable): Telephone: <br />� oto <br />1. Categories: <br />Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct <br />& Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide <br />by the following• <br />- <br />Foods containing cream, custard, or meat fillings are potentially hiazardous <br />and are T ALLO <br />foods that are defined as "non-potentially hazardous" are approved for <br />preparation by a Co a Food <br />Op <br />These foods include items that do not require refrigeration to keep thein <br />safe from bacterial gro <br />coul <br />cause of food-borne illness. <br />3. Products: <br />Provide a list of all products you are preparing. If preparing jams, jellies, <br />or fruit butters include a list of <br />ingredients (attach separate pagetf needed). <br />Food List: P <br />C hOCt <br />e Cq �e <br />19 t1kk6� �+�'� <br />A, <br />t. Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one <br />abel is required if only one proct. <br />ct is <br />made). IjC(-k— \,V P, e1 F9 <br />i. Water Source: <br />P ase check what type of water source is being used at the CFO: <br />City Water ❑ Private Well` <br />'If a private well, attach all updated water sample results (including qua <br />erly bacteria and Nitrate results <br />i. Food Processor Course: <br />Attach food handler certification for owner and each individual that wen <br />not submittd with initial applic <br />ion <br />(including family members and/or employees). �`tk �� <br />� U " <br />38 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-31420 1 <br />209 464-0138 1 www.sjgov.o <br />/EH1 <br />ent <br />Only <br />ation. <br />I be a <br />