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I <br />SAN JOAQUIN <br />CFO Business Name <br /> ’Class B’ (Direct & Indirect Sales) S486'Class A' (Direct Sales Only) SI86 <br />2. <br />3. <br />Food List:Custom sugar cookies <br />4. <br />5. <br />6. <br />1868 E Hazelton Avenue | <br />I <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Environmental Health Department <br />Creative Cookies by Diana <br />Cl O Physical Address <br />7640 W Alycia Cl <br />Website (If applicable) <br />Date <br />J/4/2Q26_____ <br />CFO Zip <br />95304 <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 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 />Stockton. California 95205 | T 209 468 3420] F 209 464-0138 | www.sjcehd com <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 />1. Categories: <br />Water Source: <br />Please 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 quarterly bacteria and Nitrate results ) <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 />Owner Name <br />Diana Jennings <br />CFO City <br />Tracy <br />'c,c’p,’on'’ %F(