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41 " SAN JOAQUIN COUNTY <br /> Al ENVIRONMENTAL HEALTH DEPARTMENT <br /> �•. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �� lRaa `�.• Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sogov.org/ehd <br /> COTTAGE FOOD OPERATOR REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Date: <br /> "�f f-2 Da� 1 z.J <br /> CFO Physical Address: CFO City: CFO ZIP: <br /> Website(If applicable): TELEPHONE: <br /> 1. Categories: <br /> [\ "Class A"(Direct Sales Only)$125 ❑ "Class B" ( Direct& Indirect Sales)$250 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: t <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br /> Only foods that are defined as"non-potentially hazardous"are approved for preparation by a Cottage Food <br /> Operation (CFO). These are food items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a 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 /> '1'96. Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ❑ Fruit Butter** <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes ❑ Dried Fruit <br /> ❑ Granola/Cereals ❑ Nut Butters ❑ Dried Tea ❑ Trail mix <br /> Sweet Sorghum <br /> ❑ Syrup ❑ Roasted Coffee ❑ Chocolate Covered Nonperishable Food <br /> ❑ Other: <br /> **These items must comply with standards described in Part 150 of Title 21 of the Code of Federal Regulations <br /> http://www.accessdata.fda.g ov/scd pts/cdrh/cfdocs/cfCFR/C F RSearch.cfm?CFRPa rt=150 <br /> EHD 16-27 5/3/2013 1 CFO REG/PERMITTING FORM <br />