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SAN JOAQUIN <br /> Environmental Health Department <br /> C 0 U r <br /> Greatness q s here 0 <br /> TTAGE <br /> COR GISTRAOT ON PE MITOT NG FORM Oct �1 <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) pFRiy�MFNTq� �ON <br /> sFR�F��rhr <br /> CFO Business Name. Owner Name: Date: S <br /> CFO Physics Address: CFO City: CFO Zip: <br /> P�ecmooi- °tS 3Y 1 <br /> Website(If applicable): Telephone: <br /> 1. Categories: a O�j• d a 12M 14'1 <br /> QK "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 /> 2Baked 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 " 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 ❑ ❑ Donuts and <br /> Butters Waffles <br /> ❑ Granola/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 LlDried <br /> Soup Mixes F-1 Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />