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SAN 10 A Q U I N Environmental Health D9artment <br /> COON -v- <br /> JUL 2 l 2029 <br /> COTTAGE FOOD OPERATIONS (CFO) r,NMENTAL HEAT <br /> REGISTRATION/PERMITTING FORM MITISERVICES <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name Date: <br /> M �NKYIS MA CIA C MEFrJAKS11 IDu ULNA lI i9 �Oa\ <br /> CFO Physical Address: CFO City: CFO Zip: <br /> -7()'2 Iz4C KCR I1461 S-T TRACY q 5311 <br /> Website(If applicable): Telephone:11�a) 4.16 _ � 0 <br /> n / <br /> 1. Categories: f`"r I <br /> LTJ "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: M T <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 /> 0" Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> 12 <br /> / Baked Goods ElDried Pasta ❑ Honey ElPopcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> 101" Buttercream L� Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing* Fondant/Gumpaste* Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/NutFried or Baked <br /> ❑ Fruit Empanadas ElFruit Tamales/Pies ElButters ElDonuts 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 209 464-0138 1 www.sjgov.org/EHD <br /> ?J�,( Ssq-10t 3 S <br />