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;q SANAHON Environmental Health Department <br /> RECEIVED>o. .� <br /> —COUNTY— FIVE® <br /> �qtl Greotness grows here. <br /> DEC 18 2020 <br /> COTTAGE FOOD OPERATIONS (CFO) ENVIRONMENTAL HEALTH <br /> REGISTRATION/PERMITTING FORM PERMIT/SERVICES <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> c50UMC5 5ALE 5ftp fill-tspq �-'0 12-15-ZD <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 2o-4 -DP— RI Pn N Q53(o(o <br /> Website(If applicable): Telephone: <br /> 204- 404-47_6Z <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $155 "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. "Class 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 [I Honey E] Popcorn <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> Buttercream Buttercream Ground <br /> ElFrosting/Icing* El Fondant/Gum paste* ❑ Flat Icing ElChocolate <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 ElCandied Apples ® Caramel/Fudge Marshmallow <br /> Bars* <br /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- ElVegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br /> S <br />