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SAN J OAQ U I N Environmental Health Repartment <br /> COUNTY O ^ <br /> Jq v o <br /> COTTAGE FOOD OPERATIONS (CFO) �NpyRO,y ��ZO <br /> REGISTRATION/PERMITTING FORM FRMi 2Iq 1y <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) R�4ly, y <br /> usin ss S me I w � Owner Name: `� � Date. <br /> CFO Physical Address: CFO Citi. !`J� Y CF^OO ZZ : I <br /> � ) c I <br /> Website(If applicable): Tele one: <br /> U <br /> 1. Cate ories: <br /> "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <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 NO OWE Only <br /> foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage eration. <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 /> 3. "Class A" Self Certification Checklist: <br /> ❑ Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> XBaked Goods ❑ Dried Pasta X Honey Popcorn/ <br /> Popcorn Balls <br /> Candy X Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros Waffle Cones ❑ Dried Grain Mixes Fruit Butter** <br /> Buttercream ButtercreamFlat Icing ❑ Ground <br /> Frosting/Icing Fondant/Gu m paste* ;9_1� Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas XFruit Tamales/Pies ❑ Butters Donuts and <br /> ?I Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> Cotton Candy Candied Apples Caramel/Fudge Marshmallow <br /> \ / Bars* <br /> Dried or Dehydrated Dried Vegetarian- <br /> ❑ Vegetables ❑ Based Soup Mixes ❑ Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />