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SAN JOAQUIN Environmental Health Department COUNTY— 'wraalr Greotness grows her CFO Business Name: Mr Winteas COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING FORM (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) Owner Name: Clint Elliott Date: 10-29-2021 CFO Physical Address: CFO City: CFO Zip: 23346 S Frederick Rd Ripon 95366 Website (If applicable): Telephone: 209-479-1194 1. Categories: V "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 2. Prohibited Items: Initial if you agree to abide by the following: CE 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: ® Checklist completed ("Class A" CFOs Only) 4. Products: Please check the items you will be preparing and/or selling. ❑ Baked Goods ❑ Candy ❑ Churros ❑ Buttercream Frosting/Icing* ❑ Dried Mole Paste ❑ Fruit Empanadas ❑ Granola/Cereals ❑ Cotton Candy ❑ Dried Pasta ❑ Dry Baking Mixes ❑ Waffle Cones E]Buttercream Fondant/Gu m paste* ❑ Herb/Spice Blends ❑ Fruit Tamales/Pies ❑ Seasoning Salt ❑ Candied Apples ❑ Dried or Dehydrated ❑ Dried Vegetarian - Vegetables Based Soup Mixes Ll El Popcorn Popcorn Balls ❑ Mustard ❑ Vinegar ❑ Dried Grain Mixes ❑ Fruit Butter** ❑ Flat Icing El Chocolate Chocolate ❑ Pizzeles ❑ Jams/Jellies** Nut Mixes/Nut Fried or Baked ❑ ❑ Donuts and Butters Waffles ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit Salted Marshmallows/ ❑ ❑ Marshmallow Caramel/Fudge Bars ❑ Vegetable and Potato Chips 1868 E. Hazelton Avenue I Stockton, California 96205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/EHD