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�1N1" SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sicehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> KZY�c�S (weP14iCtq5 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> SIJ C'(ac�gi0ll° Layle- r)+eer. 01034 <br /> Website(If applicable): Telephone: <br /> kC11-Ct ZP.0 <br /> 1. Categories: <br /> K "Class A' (Direct Sales Only) $125 ❑ "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 /> Baked Goods ElDried Pasta E] Honey Popcorn! <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> Buttercream Buttercream Ground <br /> Frosting/Icing* Fondant/Gu m paste* ❑ Flat Icing ❑ Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ Donuts and <br /> 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 /> EHD 16-27 6/29/2015 1 CFO REG/PERMITTING FORM <br />