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SAN - J OA Q U I N Environmental Health Department —COUNTY— COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING FORM (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) CFO Business Name:- Owner N(� Date: I Teak 6u �I,,e_ Q y e n N net War reh i 23-ZD CFO Physical Address: CFO City: CFO Zip: -2.22, WPA LaFlor Lant MOUVJ41nI_oV54P_ g53gI Website(If applicable): Telephone: 11 O 9\ 2q I^q Dog 1. Categories: "Class A" (Direct Sales Only) $155 ❑ "Class B"(Direct& Indirect Sales)$310 2. Prohibited Items: Initial if you agree to abide by the following: M VY Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food-borne illness. 3. "Class A" Self Certification Checklist: [P Checklist completed ("Class A" CFOs Only) 4. Products: Please check the items you will be preparing and/or selling. [ Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ Popcorn Balls ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** Buttercream Buttercream Ground g g* '�" Fondant/Gum ❑ Flat Icing ❑ Prostin //cin paste Chocolate ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** Nut Mixes/Nut Fried or Baked ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ Donuts and Waffles ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit Salted Marshmallows/ F-1CottonCandy Candied Apples Caramel/Fudge El Marshmallow Bars* ❑ Dried or Dehydrated ❑ Dried Vegetarian- ❑ Vegetable and Potato Chips Vegetables Based Soup Mixes