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S A N D OA Q U I N Environmental Health Department <br /> —COUNT Y-_ <br /> Greotness grows here. <br /> CO I AGEE ..00O Opi=R'ATIO.NS jC O) <br /> REGI-STRATION/PERMITTING FORM <br /> (CALIFO NIAHOMEMAJE°I=✓.OD ACT AB 616(GATT.0)) <br /> CFO Susinss?game: Owner?name, Date: <br /> CFO Physical Address: CFO City: CFO Zip: <br /> Website(If applicable): Telephone: <br /> -t,,e CeD Lie,11 ur5e 709 L0 nla;,I - Lo m ���= L3 <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 followin� <br /> Foods containing cream,, custard, or meat fft1ings are poteatiafly hazardous aid are NOT ALLOWED. Only <br /> foods that are defined as "nor-potentiaRy 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 Butters' <br /> Flat Icing <br /> Buttercream Buttercream f�l Ground <br /> ElFrosting/Icings ElFondant/Gurn paste* ❑ Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Emlpanadas ❑ '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- <br /> Vegetable and Potato-Chips, <br /> Vegetables E] Dried <br /> 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 />