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A �. SAN JOAQUIN COUNTY <br /> y� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • 1AF5 <br /> ° Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name:/ A 1� It 1 Date: <br /> CFO Physical Address: y1�J 1L�` ly 1 Cly-rxLF- CFO City: CFO Zip: <br /> x135 t itne L2,nAen 9593(o <br /> Website(If applicable), Telephone: <br /> ,An9a <br /> - 4� - 7241L <br /> cr) <br /> 1. Categories: / i <br /> El "Class A" (Direct Sales Only) $125 Lg "Class B" (Direct& Indirect Sal $25� <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. <br /> Only foods that are defined as"non-potentially hazardous"are approved for preparation by a Cottage Food <br /> Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. "Class A" Self Certification Checklist: <br /> ❑ Checklist completed ("Class K CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> [� Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn <br /> [7� Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ❑ Fruit Butter** <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes ❑ Dried Fruit <br /> ❑ Granola/Cereals ❑ Nut Butters ❑ Dried Tea ❑ Trail mix <br /> ❑ Sweet Sorghum ❑ Roasted Coffee 0� Chocolate Covered Nonperishable Food <br /> Syrup <br /> ❑ Other: <br /> These items must comply with standards described in Part 150 of Title 21 of the Code of Federal Regulations <br /> http,//www accessdata fda gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch-cfm?CFRPart=150 <br /> EHD 16-271/6/2014 1 CFO REG/PERMITTING FORM <br />