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SAN 10AQUIN Environmental Health Department <br /> --COU NTY - <br /> G-ro'noss vows here. AMC <br /> COTTAGE FOOD OPERATIONS (CFO) M <br /> ( ) AR ?8 ?019 <br /> REGISTRATION/PERMITTING FORM Eniv�Ro <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO))pERMMS�'-RV/H��Ty <br /> FO Business Name: Owner Name: Date: L�" jfs <br /> 2lo N 0,3120r s Gjtli es CtnrlQ e Gordon <br /> CFO Physicaldress: CFO City: CFO Zip: <br /> 1 ia)k, Vt_cos G'r 5Laraoc t <br /> Website(If applicable): Telephone: <br /> 1. Categories: <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 NOT ALLOWED. Only <br /> foods that are defined as"non-potentially hazardous" are approved for preparation by a Cottage Food Operation. <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 /> Baked Goods F] Dried Dried Pasta ❑ Honey / Popcorn/ <br /> `- Popcorn Balls <br /> Candy �f Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> Buttercrearn Buttercream . Flat Icing r� Ground <br /> Frosting/Icing* 10 Fondant/Gumpaste* g �f Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends Yj 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 /> �y' Salted ,,{ Marshmallows/ <br /> ACotton Candy Candied Apples Caramel/Fudge W Marshmallow <br /> Bars <br /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- ElVegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />