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p(2. OSM SHIH <br />Environmental Health Department <br />"Class A" (Direct Sales Only) $186 “Class B” (Direct & Indirect Sales) $486 <br />2. Prohibited Items: <br />3. Products: <br />Food List: <br />feor-T ord\J-ef e-xp : <br />4. Product Labeling: <br />5. Water Source: <br />*lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />6. Food Processor Course: <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjcehd.com <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 />Initial if you agree to abide by the following: Fj/fi <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 />Please check what type of water source is being used at the CFO: <br />City Water Private Well* <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 />Provide a list of all products you are oreoaring. If preparing jams, jellies, or fruit butters include a list of <br />ingredients (attach separate page if needed). <br />CFO Zip: <br />9^3^^ <br />1. Cdteijuries: <br />CFO Physical Address: <br />SAN JOAQUIN <br />-COUNTY- <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />A <br />Owner Name: F l/ercteXie Date: 3/6/^02^ <br />CFO City: <br />Website (If applicable): ' . . Telephone: