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SAN J 0 A Q U I N Environmental Healt 0Department <br /> COUNTY <br /> MAY 01 2019 <br /> COTTAGE FOOD OPERATIONS (CFO) ENVIRONMENT <br /> REGISTRATION/PERMITTING FORM PERMiTiSERV1C SL7H <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> CFO Physical Address: CFO City: CFO Zip: <br /> Z��ir o KED_&i•JU o1\1 tA64y TD 4-1-0 <br /> Website(If applicable): e /jam^[/�1 Telephone: <br /> 691y\ (27�c?) 7�7k 1 2- 2- 0 <br /> 1. Categories: <br /> r ' "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 cornpleted ("Class A" 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 /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> XButtercream * ElButtercream * El Flat Icing El Ground <br /> Frosting/Icing Fondant/Gumpaste Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas Fruit Tamales/Pies El Donuts and <br /> Butters Waffles <br /> AGranola/Cereals ❑ Seasoning Salt Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted � Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples Marshmallow <br /> Caramel/Fudge Bars* <br /> Dried or Dehydrated Dried Vegetarian- <br /> ❑ Vegetables ❑ Based Soup Mixes El 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 />