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SAN JOAQUIN Environmental Health Department <br /> —COUNTY <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACTT AB 1616 (GATTO)) <br /> CFO Business Name: 'O naName: <br /> Qimp'� Me l iss& �A q Daie: /� I� � 0 <br /> CFO Physical Address: .jC '.Fn City: CFO Zip: <br /> ID27arbo UtW4- sh&tvn g52aq <br /> Website(If applicable): Telephone: (M) <br /> 4_71- 5410 <br /> T_7 1_ G 1 iJ'fL 10 I <br /> 1. ate ories: <br /> "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct& Indirect Sales) $310 ]M n <br /> 2. Prohibited Items: Initial if you agree to abide by the following:`' &F <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. "Class A" Self Certification Checklist: <br /> Id Checklist completed ("Class A"CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods El Dried Pasta El Honey El Popcorn <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> 0 Buttercream ❑ Buttercream Flat Icing Ground <br /> Frosting/Icing` Fondant/Gumpaste* g ❑ Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars' <br /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- ❑ Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com <br />