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SAN 1 OA Q U I N Environmental Health Department <br />C O U N T Y -_-__ <br />„ Greatness grows here. <br />I'sp�D <br />COTTAGE FOOD OPERATIONS (CFO) OCT 18 1019 <br />REGISTRATION/PERMITTING FORM tWRONmeNTAL11SALr8 <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO ffRA41r/SEM�CES <br />CFO Business Name: Owner Name: Date: <br />-TVANK YOU MATCHA -JOCtYK) ?>&S)LIQ )0 IF) Iq <br />CFO Physical Address: CFO City: CFO Zip: <br />"ENtQ 1�640 DF L-fi Atzo? X53-30 <br />Website (If applicable): Telephone: <br />3-s3 <br />1. Categories: <br />X"Class A" (Direct Sales Only) $155 <br />❑ "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 />0 Baked Goods <br />❑ Candy <br />❑ Churros <br />❑ Buttercream <br />Frosting/Icing` <br />❑ Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ Cotton Candy <br />❑ Dried Pasta <br />❑ Dry Baking Mixes <br />❑ Waffle Cones <br />❑ Buttercream <br />Fondant/Gumpaste* <br />❑ Herb/Spice Blends <br />❑ Fruit Tamales/Pies <br />❑ Seasoning Salt <br />❑ Candied Apples <br />❑ Honey ❑ Popcorn/ <br />Popcorn Balls <br />❑ Mustard ❑ Vinegar <br />❑ Dried Grain Mixes ❑ Fruit Butter" <br />❑ Flat Icing ❑ Ground <br />Chocolate <br />❑ Pizzeles ❑ Jams/Jellies** <br />El Butters <br />Mixes/Nut � DonutsFried and Baked <br />Butters Waffles <br />❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br />Salted Marshmallows/ <br />❑ Caramel/Fudge ❑ Marshmallow <br />Bars* <br />Dried or Dehydrated ❑ Dried Vegetarian - <br />Vegetables ElDried <br />Soup Mixes E] Vegetable and Potato Chips <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />