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Download Cottage Food Registration Form - Wayne County Health Department
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Wayne County Health Department 405 North Basin Road Fairfield, IL 62837 (618) 842-5166 APPLICATION TO REGISTER A COTTAGE FOOD OPERATION Name of Business: __________________________________________________________________________ Owner of Business: ___________________________________________ Phone #: ______________________ Address where food is being prepared: __________________________________________________________ Mailing address (if different from above): ________________________________________________________ Location of Farmers’ Markets: _________________________________________________________________ __________________________________________________________________________________________ Illinois Department of Public Health Certified Food Manager(s): Name:_________________________________ ID#:__________________________Expires: _______________ Name: _________________________________ID#:__________________________Expires:_______________ Prohibited Items: Pumpkin pie, sweet potato pie, cheesecake, custard pies, and cream pies, as well as pastries with potentially hazardous fillings or toppings. Pumpkin, banana, and pear butters are not allowed. Rhubarb, tomato, pepper and watermelon jellies or jams are not allowed as well. Allowable Products - Please circle or list the items you will be making and selling: Dry herb dry herb blend dry tea blend intended for end-use only: _______________________________ Jam / Jelly / Preserves / Fruit Pie: apple apricot grape peach plum quince orange nectarine tangerine blackberry raspberry blueberry boysenberry cherry cranberry strawberry red currants combination of the above: _____________________________________________________________________ Fruit Butter: apple apricot grape peach plum quince prune Breads / Cookies / Cakes / Pastries: _________________________________________________________________ __________________________________________________________________________________________________ Product Labeling – All cottage foods must be labeled with the following information: The name and physical address of the cottage food operation The common or usual name of the food product All ingredients including colors, artificial flavors, preservatives, listed in decreasing order of prominence by weight Statement: “This product was produced in a home kitchen not subject to public health inspection that may also process common food allergens.” The date the product was processed Allergen labeling as specified in federal labeling requirements Note: Attach copies of all product labels with this application Owner’s Statements I, __________________________________, agree to grant access to Wayne County Health Department to conduct an inspection of my cottage food operation’s primary domestic residence in the event of a consumer complaint or foodborne illness outbreak. Signature: __________________________________ Date: ____________________ Please return the completed, signed application form and copies of all product labels to: Wayne County Health Department 405 North Basin Rd. Fairfield, IL 62837
