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SAN JOAOUIN Environmental Health Department <br />"Class B” (Direct & Indirect Sales) S486□ <br />not submitted with initial application <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />tmbers and/or employees) <br />*>io« klon Caliloriiia 9.>7U5 | T 209 41)8-3420 | F 209 464-0138 | www.sjcehd com <br />of water source is being used at the CFO: <br />□ Private Well* <br />5. Water Source: <br />Please chock what type <br />L/Cily Water <br />C O Pucinos Name <br />c <j d'oieiFTS <br />v'TO Addrrtt. <br />/A37 ro^V eru/rr <br />Website (I* applicable' <br />CFO City <br />/MCJ <br />Telephone <br />1. Categories: <br />"Class A' (Direct Sales Only) $186 <br />•If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <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: / C^iacA^i <br />6. Food Processor Course: <br />Attach food handler certification for owner^ each individual that were <br />(including family rner.— <br />1868 1 Ha/ehon Avenue | <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 />food1; that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be <br />cause of food-bome illness. <br />4. Product Labeling: <br />Attact, two labels to this form for two of your CFO products (only one label is required if only one product is <br />made) <br />(hvnot Namr Al. /OCM Date <br />CFO Zip <br />‘Zrj’yz