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SAN JOAQUIN COUNTY <br /> a - ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> COTTAGE FOOD OPERATOR REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Dat <br /> 9-J <br /> �-_ aLo <br /> CFO Physical Address: CFO City: CFO ZIP: <br /> 1. '�1i 1 l l K)V'C1b PINR 6T ry 3.3 to <br /> Website(If applicable): <br /> vuu)w ��T�2a-t <br /> 1. Categories: <br /> / "Class A" (Direct Sales Only) $125 ❑ "Class B" ( Direct& Indirect Sales) $250 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALL WED. <br /> Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br /> Operation (CFO). These are food items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. "Cla s A" Self Certification Checklist: <br /> Checklist completed ("Class A' CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods ❑ Dried Pasta ❑ Honey '"V( Popcorn <br /> [[ Candy ,)( Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ❑ Fruit Butter** <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies'* <br /> [$� Fruit Empanadas t( Fruit Tamales/Pies [y Nuts/Nut Mixes ❑ Dried Fruit <br /> IX Granola/Cereals ❑ Nut Butters ❑ Dried Tea EX Trail mix <br /> Sweet Sorghum <br /> El Syrup ElRoasted 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/cd rh/cfdocs/cfCFR/CFRSearch.cfm7CFRPart=150 <br /> EHD 16-2712/27/2012 1 CFO REG/PERMITTING FORM <br />