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o��� _ SAN JOAQUIN COUNTY <br /> <' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Q <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sicehd.com FEe 2 <br /> fNVi,/o 6 ?016 <br /> COTTAGE FOOD <br /> ) <br /> EGISTRAT ON!ERM TTING FORMPfRMTM RV/C g� <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> �)2b_ )6 <br /> CFO physicals Address: CFO City: U CFO Zip: <br /> )$c�Cj RPrJmo 7)L dP_ Ln&n4PtA _ CAO 9 533(0 <br /> Website(If applicable): Telephone: <br /> 1. Catestories: <br /> ❑ "Class A" (Direct Sales Only) $125 4 "Class B (Direct& Indirect Sales) $250 <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 A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> �/ Popcorn/ <br /> IBJ Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn Balls <br /> 9 Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> Buttercream Buttercream Ground <br /> Frosting/Icing* ❑ Fondant/Gumpaste* ❑ Flat Icing ❑ Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies'* <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Donuts and <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ElButters <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> F-1Cotton Candy [71Candied Apples ElCaramel/Fudge ❑ Marshmallow <br /> Bars` <br /> EHO 16-27 6/29/2015 1 CFO REG/PERMITTING FORM <br />