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SANJQQQQIN Environmental Health Department <br /> —COUNTY— <br /> t <br /> GreoEness qrows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> KCFO Business Name: Owner Name: Date: <br /> 1 CIC CC-N .Zone C°, rro o\\blv - iO � w a <br /> CFO Physical Address: CFO City: CFO Zip: <br /> vw *118 \yo„Aq 533` 1 <br /> Website(If applicable): Telephone: q <br /> lAlO 0.f�0�I1Ml1P h�PIIlf9 �DIY7 WD 1 — <br /> 1. Categories:Al ,_/ <br /> "Class A" (Direct Sales Only)$155 LSI "Class B" (Direct&Indirect Sales)$310 p <br /> Prohibited Items: Initial if you agree to abide by the following: all- <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED, ; my <br /> foods that are defined as"non-potentially hazardous"are approved for preparation by a Cottage Food Operl tion. <br /> 'These foods include items that do not require refrigeration to keep them safe from bacterial growth that couldl be a <br /> cause of food-bome illness. <br /> `. "Class A" Self Certification Checklist: <br /> 1 ❑ Checklist completed("Class A" CFOs Only) <br /> !!!! ,Products: <br /> Please check the items you will be preparing and/or selling. <br /> ( Popcom/ <br /> Baked Goods LI Dried Pasta ❑ Honey ❑ Popcorn Balls <br /> ❑ Candy Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> Buttercream Buttercream Ground <br /> ❑ Frosting/Icing' ❑_ Fondant/Gumpaste' E] Flat Icing ❑ Chocolate <br /> Dried Mole Past e (y/Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> Nut Mixes/Nut Fried or Baked <br /> Fruit Empanadas ❑ Fruit Tamales/Pies ❑ ❑ Donuts and <br /> J Butters � Waffles <br /> Granola/Cereals �Seasoning Salt © Trail Mix/Dried Fruit ISI( Dried Fruit <br /> I— Salted Marshmallows/ <br /> LLLJJJ Cotton Candy ❑ Candied Apples ElEl Marshmallow <br /> I � Caramel/Fudge Bars, <br /> Dried or Dehydrated dDried Vegetarian- ❑ Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org ID <br /> i <br />