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SAN 10 A Q U I N Environmental Health Department <br /> +�• P`. <br /> --- COUNTY-- Rtmv <br /> ED <br /> Greatness grows here <br /> JUL 17 2019 <br /> COTTAGE FOOD OPERATIONS (CFO) ENVIRONI<IENTAL HEALTH <br /> REGISTRATION/PERMITTING FORM DEPARTMENT <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> k <br /> CFO Physical Address: FO City: CFO Zip: <br /> Moot PO (Q ( I-A —7cas�l , C. fA cf 1 c q <br /> Website(If applicable): Telephone: _ 7 <br /> C 7 I <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 ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> Buttercream ❑ Buttercream El Flat Icing ❑ 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 ❑ ❑ Donuts and <br /> Butters 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- <br /> ❑ Vegetables L1Dried <br /> Soup Mixes ❑ Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209468-34201 F 209464-0138 1 www.sjcehd.com <br />