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SAN JOAQUIN Environmental Health Depar-tr lent <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name Owner Name. Date: <br /> P)'S � r'��4n _ Cierra ZQQ(' ra Gy /tS 1 ion <br /> CFO physical Address: CFO CO: CFO zip <br /> 179L) VyW-eJ VA wa-r,_ I —albr"o 9s�3v <br /> Wobuite til applicable) Telephone: <br /> 1u5U - 303 -4370 <br /> 1. Categories: <br /> 1�j Class A (Direct Sales Only) $155 ❑ `Class B' (Direct 8 Indirect Sales)$310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: ('_ <br /> Foods containing cream, custard, or meet 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 andlor selling <br /> [� Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> ❑ Buttercream11Buttercream El Flat Icing El Chocolate Frostingllcing' Fondant/Gumpaste' Chocolate <br /> ❑ Dried Mole Pasta ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> ❑ FruitEmpanedas ❑ Fruit Tamales/Pies ❑ Nut Mixes/Nut Fried or Baked gutters <br /> [I Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trall Mat Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples ElCaramel/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 209 468-34201 F 209 464-0138 1 www sigov org/EHO <br />