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SAN J OAQ U I N Environmental Health Department <br /> COU NTY <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> F Business Name: Owner Name: Date: <br /> r -}y-c, C(,ke_s� lt-<�,CAS � , LD�-e Ube_<�Scr� <br /> CFO Physical Address: CFO Cit : �,e <br /> CFO Zip: <br /> k$A '5T) �PpenL-el t✓.-N k\6�� l 5 3.3 .7 <br /> Aebsite(If applicable): Telephone: <br /> IN 2-09 - zti c - ?__7(c ko <br /> 1. Categories: <br /> Z "Class A" (Direct Sales Oy) $1� ❑ "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. "Cla s 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 /> LK Baked Goods ❑ Dried Pasta ❑ Honey n/Pbpcorn/ <br /> ��'' Popcorn Balls <br /> []Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros [Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> uttercream uttercreamFlat IiGround <br /> Frosting/Icing'` Fondant/Gumpaste* cng El <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nutied or Baked <br /> ❑ Fruit Empanadas ElFruit Tamales/Pies ElButters Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> ,—,malted arshmallows/ <br /> Cotton Candy Candied Apples 4�' Caramel/Fudge Marshmallow <br /> Bars* <br /> Dried or Dehydrated Dried VegetarianEl- <br /> ❑ Vegetables ElDried <br /> Soup Mixes 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 />