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R <br />\ i —COUNTY <br />\c,.. <br />\--:ktra0. <br />SANJUAOUIN <br />Groof <br />Environmental Health Department <br />176\ 002-7 to-4 2 <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />Date: <br />05101 I 2o2 <br />CFO Zip! <br />c153 I <br />CFO Business Name: <br />CAKES NU <br />CFO Physical Address: <br />5 V/ fTH PL 10 ouN AIN-) H DOS r <br />Owner Name: <br />USFIPI DE5111 <br />CFO City: <br />Website (If applicable): Telephone: <br />;lo- .766 -8 6 5 <br /> <br />Categories: <br />S -Class A" (Direct Sales Only) $186 LI 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-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 />Cu-sio-rn CcLiccs, Cuip(0,1(0 , Calces')cles <br />ecse-r-t- c„,j <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 />IJ City Water E] 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.com