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S A 6J O A Q U I N Environmental Health Department <br /> COUNTY- -- <br /> �'D <br /> COTTAGE FOOD OPERATIONS (CFO) MAR 2 0 2020 <br /> REGISTRATION/PERMITTING FORM ENVIRONMENTALH <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATT O)) PERMIT/SERVICES�TH <br /> CFO Business Name: Owner Name: Date: <br /> AlysSn'S Cy-erat-00- CoJec on e, Awssiq Mw W- 1 i ILti,S 0S-Z0 -20 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> S 19 M c.Kef- C+ R ipor q S 3(ow <br /> Website(If applicable): Telephone:�2�� <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 /> 1d 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 * ElButtercream [� Flat Icing El Chocolate 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 ❑ 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 /> ElDried <br /> ElDried <br /> Soup Mixes F-1 Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />