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SAN J O A Q U I N Environmental Health Department <br /> —COU N Y <br /> Greotness grows here.. <br /> RECEOVEO <br /> COTTAGE FOOD OPERATIONS (CFO) MAY 2 2 2019 <br /> (CALIFORNIA HOMEMION/PERMITTING FORM AADE FOOD ACT AB 1616 GATTO)) PIERMM sER�I" <br /> C EALTI-f <br /> CFO Business Name: Owner Name: Date <br /> 4L/ <br /> CFO Physical Address: CFO City: CFO Zip: <br /> /.'Z <br /> Website(If applicable): Telephone: <br /> 1. Categories: <br /> Rf "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: s, <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 /> (A Checklist completed ("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 /> E] <br /> Buttercream Ground <br /> ❑ Frosting/Icing" ❑ Fondant/Gumpaste E] 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 /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- ❑ Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />