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a ECY' IVE <br /> _ JAi4 2 8 2D21 <br /> _ z SAN JOAQUIN Enviromtff IfENri*aNth,�Department <br /> a'Z <i —COUNTY— PERMIT/SERVICES <br /> C,irIP <br /> Greatness gro•.vs here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name Owner NameDate: <br /> KOOKIGNOW by cSiWA SiLma Luekt o Ic?/W21 <br /> CFO Physical Address: CFO City CFO Zip: <br /> 2725 'PAWMI PKIN-1 Nt�. 5311D TrOiq 6153aq <br /> Website Qi applicable) Telephone: <br /> 209- H02-3g3D Slerralue Ojmall.CUYI <br /> 1 ate ones: <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-bome illness_ <br /> 3. "Class A" Self Certification Checklist: <br /> XChecklist completed ("Class A'CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods [IDried Pasta ElHoney ElP Po comX / <br /> Popcom Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> ❑ Buttercream ❑ Buttercream El Flat Icing El Ground <br /> Froshng/Icing' Fondant/Gumpaste' Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> Nut MixeslNut 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- El and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />