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S A N 1 D A U H I N Llivironryiental Health Department <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> Cl C Piterrwme Nnmp Ihvnpi Namp AJr IA4Af Date <br /> (_' T d SWC& 3 Qf} CL trl.LC f�L/l�Gr+v /T <br /> ,'r,,1',111— al Adfin", C V 0 Cdy CFO Zip <br /> id-37 rater err er. r #q 9Y377- - - <br /> %\1et`srrP I If arlirr+['ahlP l Teie �.,00ne <br /> 1. Categories: <br /> P-*' "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: <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-Dome 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: �� �5' f C44 <br /> 4. Product Labelin <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 /> Pluase check what type of wafer source is being used at the CFO: <br /> Le/cAty Water ❑ Private Well" <br /> 'If a private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: <br /> Attar,h food handler certilreatrun for uwner and each individual that were not submitted with initial application <br /> (rr(cludrrrg family rrrentbers and/or employees) <br /> I r�.�,F;Hr,r� Atirnur t `,tur klr�n t;rililurnfa T 209�IGf9•;i� 0 1 F "irii wzl-o 138 1 wwGw.sjcettd corn <br />