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SANJOAQUlN Environmental Health Department <br />COUNTY <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: Date: <br />i- I D i. ..f X ..r . ., , <br />CFO Physical Address: / CFO Cify: - ct-U zip: <br />)-o A 9 5 zq <br />Website (if applicable): Telephone: <br />�i4 45 30 - 3-1 5-- D, -i K <br />rT <br />1. Cate ories. <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 <br />❑ Candy <br />❑ Churros <br />ElButtercream <br />Frosting/Icing* <br />❑ Dried Mole Paste <br />❑ <br />Dry Baking Mixes <br />❑ <br />Waffle Cones <br />❑ <br />Buttercream <br />Fondant/Gumpaste* <br />❑ <br />Herb/Spice Blends <br />❑ Fruit Empanadas ❑ Fruit Tamales/Pies <br />❑ Granola/Cereals <br />❑ Cotton Candy <br />❑ Seasoning Salt <br />❑ Candied Apples <br />❑ <br />Mustard <br />❑ <br />Dried Grain Mixes <br />❑ <br />Flat Icing <br />❑ Popcorn/ <br />Popcorn Balls <br />❑ Vinegar <br />❑ Fruit Butter" <br />❑ Ground <br />Chocolate <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies** <br />Fried or Baked <br />El <br />Mixes/Nut <br />❑ <br />Donuts and <br />Butters <br />Butters <br />Waffles <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />Salted Marshmallows/ <br />❑ Caramel/Fudge ❑ Marshmallow <br />Bars* <br />❑ Dried or Dehydrated ❑ Dried Vegetarian- ❑ Vegetable and Potato Chips <br />Vegetables Based Soup Mixes <br />1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />