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cYN t�; <br /> A- •�. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ;f Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sagov.org/ehd <br /> r <br /> COTTAGE FOOD OPERATOR REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Date: <br /> 7rr,�, CQPC4%( CAS jC 911-gig-- <br /> CFO Physical Address: CFO City: CFO ZIP: <br /> /153 44A4 VA qu.6 !tet4W c-c 4 95_43 � <br /> Website(If applicable): TELEPHONE: <br /> 2P7 4,03-0200 <br /> 1. Categories: G-V-a rr- co r CLOtr'l . <br /> D4 "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: <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 /> `"6 Checklist completed ("Class A" CFOs Only) <br /> 4Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn <br /> ❑ Candy 'P Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ** <br /> ❑ Fruit Butter <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles <br /> ❑ Jams/Jellies** <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes <br /> ❑ Dried Fruit <br /> ❑ Granola/Cereals ❑ Nut Butters ❑ Dried Tea <br /> ❑ 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.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch cfm?CFRPart=l50 <br /> EHD 16-27 5/3/2013 1 CFO REG/PERMITTING FORM <br />