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SAN JOAQUIN Environmental Health Department <br /> - COUN v-- <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Omer Name: Date: <br /> 5Re2,+P -Delej CaL�d1e5 Re4 Sow)rn 0. -Lot -21 <br /> CFO Physical Address: CFO City: y CFO Zip: <br /> 12)\O\ C+ Maus o C 0" X 5331 <br /> Website(If applicable): Telephone: <br /> (�n�l g3O� b3�ba <br /> 1. Categories: <br /> ❑ "Class A"(Direct Sales Only)$155 "Class B" (Direct 8 Indirect Sales)$310 p t <br /> 2. Prohibited Items: Initial If you agree to abide by the following: f�J <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 /> ❑ Checklist completed ("Class A"CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> F1 Baked Goods ❑ Dried Pasta ❑ Honey El Popcorn <br /> Popcorn Balls <br /> 7 , Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter* <br /> ❑ Buttercream ❑ Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing' Fondant/Gumpaste' Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> Nut Mixes/Nut Fried or Baked <br /> F-1Fruit Empanadas ElFruit Tamales/Pies 11ElButters Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> E] Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars' <br /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- E] 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 209464-0138 1 www.sigov.org/EHD <br />